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Miyamoto E, Vosoughi D, Wang J, Al-Refaee J, Berra G, Daigneault T, Duong A, Joe B, Moshkelgosha S, Keshavjee S, Tinckam K, Hwang D, Chruscinski A, Juvet S, Martinu T. Local intragraft humoral immune responses in chronic lung allograft dysfunction. J Heart Lung Transplant 2024:S1053-2498(24)01752-2. [PMID: 39097215 DOI: 10.1016/j.healun.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Donor human leukocyte antigen (HLA)-specific antibodies (DSA) and non-HLA antibodies can cause allograft injury, possibly leading to chronic lung allograft dysfunction (CLAD) after lung transplantation. It remains unclear whether these antibodies are produced locally in the graft or derived solely from circulation. We hypothesized that DSA and non-HLA antibodies are produced in CLAD lungs. METHODS Lung tissue was prospectively collected from 15 CLAD patients undergoing retransplantation or autopsy. 0.3 g of fresh lung tissue was cultured for 4 days without or with lipopolysaccharide or CD40L: lung culture supernatant (LCS) was sampled. Protein eluate was obtained from 0.3 g of frozen lung tissue. The mean fluorescence intensity (MFI) of DSA and non-HLA antibodies was measured by Luminex and antigen microarray, respectively. RESULTS LCS from all 4 patients who had serum DSA at lung isolation were positive for DSA, with higher levels measured after CD40L stimulation (CD40L+LCS). Of these, only 2 had detectable DSA in lung eluate. MFI of non-HLA antibodies from CD40L+LCS correlated with those from lung eluate but not with those from sera. Flow cytometry showed higher frequencies of activated lung B cells in patients whose CD40L+LCS was positive for DSA (n = 4) or high non-HLA antibodies (n = 6) compared to those with low local antibodies (n = 5). Immunofluorescence staining showed CLAD lung lymphoid aggregates with local antibodies contained larger numbers of IgG+ plasma cells and greater IL-21 expression. CONCLUSIONS We show that DSA and non-HLA antibodies can be produced within activated B cell-rich lung allografts.
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Affiliation(s)
- Ei Miyamoto
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Daniel Vosoughi
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Jinguo Wang
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Jamal Al-Refaee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Gregory Berra
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Tina Daigneault
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Allen Duong
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Betty Joe
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Hwang
- Department of Pathology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | | | - Stephen Juvet
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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2
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Swartz K, Mansour A, Alsunaid S. Lung Transplant for Chronic Obstructive Pulmonary Disease. Semin Respir Crit Care Med 2024. [PMID: 39029509 DOI: 10.1055/s-0044-1787560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) carries a high burden of morbidity and mortality to patient and a high cost to health care systems. Lung transplantation is a last resort available for end-stage COPD patients interested in pursuing it and meeting the strict transplant requirements. It requires commitment from patients and their loved ones to support them through this tough process. This review will cover history of transplant, indications, candidate selection, evaluation testing, transplant listing, type of transplant (single versus bilateral), posttransplant complications, immunosuppression, and rejection. It is tailored to the COPD patient when applicable; however, many aspects of lung transplantation are shared amongst all lung diseases eligible for transplant.
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Affiliation(s)
- Kyle Swartz
- Department of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ali Mansour
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York
- Department of Cardiovascular & Thoracic Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Sammar Alsunaid
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York
- Department of Cardiovascular & Thoracic Surgery, Albert Einstein College of Medicine, Bronx, New York
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3
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Hanks J, Girard C, Sehgal S. Acute rejection post lung transplant. Curr Opin Pulm Med 2024; 30:391-397. [PMID: 38656281 DOI: 10.1097/mcp.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review what is currently known about the pathogenesis, diagnosis, treatment, and prevention of acute rejection (AR) in lung transplantation. RECENT FINDINGS Epigenomic and transcriptomic methods are gaining traction as tools for earlier detection of AR, which still remains primarily a histopathologic diagnosis. SUMMARY Acute rejection is a common cause of early posttransplant lung graft dysfunction and increases the risk of chronic rejection. Detection and diagnosis of AR is primarily based on histopathology, but noninvasive molecular methods are undergoing investigation. Two subtypes of AR exist: acute cellular rejection (ACR) and antibody-mediated rejection (AMR). Both can have varied clinical presentation, ranging from asymptomatic to fulminant ARDS, and can present simultaneously. Diagnosis of ACR requires transbronchial biopsy; AMR requires the additional measuring of circulating donor-specific antibody (DSA) levels. First-line treatment in ACR is increased immunosuppression (pulse-dose or tapered dose glucocorticoids); refractory cases may need antibody-based lymphodepletion therapy. First line treatment in AMR focuses on circulating DSA removal with B and plasma cell depletion; plasmapheresis, intravenous human immunoglobulin (IVIG), bortezomib, and rituximab are often employed.
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Affiliation(s)
- Justin Hanks
- Department of Pulmonary Medicine, Integrated Hospital Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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4
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Madill-Thomsen K, Halloran P. Precision diagnostics in transplanted organs using microarray-assessed gene expression: concepts and technical methods of the Molecular Microscope® Diagnostic System (MMDx). Clin Sci (Lond) 2024; 138:663-685. [PMID: 38819301 PMCID: PMC11147747 DOI: 10.1042/cs20220530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 06/01/2024]
Abstract
There is a major unmet need for improved accuracy and precision in the assessment of transplant rejection and tissue injury. Diagnoses relying on histologic and visual assessments demonstrate significant variation between expert observers (as represented by low kappa values) and have limited ability to assess many biological processes that produce little histologic changes, for example, acute injury. Consensus rules and guidelines for histologic diagnosis are useful but may have errors. Risks of over- or under-treatment can be serious: many therapies for transplant rejection or primary diseases are expensive and carry risk for significant adverse effects. Improved diagnostic methods could alleviate healthcare costs by reducing treatment errors, increase treatment efficacy, and serve as useful endpoints for clinical trials of new agents that can improve outcomes. Molecular diagnostic assessments using microarrays combined with machine learning algorithms for interpretation have shown promise for increasing diagnostic precision via probabilistic assessments, recalibrating standard of care diagnostic methods, clarifying ambiguous cases, and identifying potentially missed cases of rejection. This review describes the development and application of the Molecular Microscope® Diagnostic System (MMDx), and discusses the history and reasoning behind many common methods, statistical practices, and computational decisions employed to ensure that MMDx scores are as accurate and precise as possible. MMDx provides insights on disease processes and highly reproducible results from a comparatively small amount of tissue and constitutes a general approach that is useful in many areas of medicine, including kidney, heart, lung, and liver transplants, with the possibility of extrapolating lessons for understanding native organ disease states.
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Affiliation(s)
- Katelynn S. Madill-Thomsen
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Applied Genomics Center, University of Alberta, Edmonton, AB, Canada
| | - Philip F. Halloran
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Applied Genomics Center, University of Alberta, Edmonton, AB, Canada
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5
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Villeneuve T, Hermant C, Le Borgne A, Murris M, Plat G, Héluain V, Colombat M, Courtade-Saïdi M, Evrard S, Collot S, Salaün M, Guibert N. Real-time and non-invasive acute lung rejection diagnosis using confocal LASER Endomicroscopy in lung transplant recipients: Results from the CELTICS study. Pulmonology 2024:S2531-0437(24)00014-X. [PMID: 38402125 DOI: 10.1016/j.pulmoe.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Traditionally, the diagnosis of acute rejection (AR) relies on invasive transbronchial biopsies (TBBs) to obtain histopathological samples. We aimed to evaluate the diagnostic yield of probe-based confocal laser endomicroscopy (pCLE) as a complementary and non-invasive tool for ACR screening, comparing its results with those obtained from TBBs. METHODS Between January 2015 and April 2022, we conducted a retrospective study of all lung transplant recipients aged over 18 years at Toulouse University Hospital (France). All patients who underwent bronchoscopies with both TBBs and pCLE imaging were included. Two experienced interpreters (TV and MS) reviewed the pCLE images independently, blinded to all clinical information and pathology results. RESULTS From 120 procedures in 85 patients, 34 abnormal histological samples were identified. Probe-based confocal laser endomicroscopy revealed significant associations between both alveolar (ALC) and perivascular (PVC) cellularities and abnormal histological samples (p<0.0001 and 0.003 respectively). Alveolar cellularity demonstrated a sensitivity (Se) of 85.3 %, specificity (Spe) of 43 %, positive predictive value (PPV) of 37.2 % and negative predictive value (NPV) of 88.1 %. For PVC, Se was 70.6 %, Spe 80.2 %, PPV 58.5 % and NPV 87.3 %. Intra-interpreter correlation (TV) was 88.3 % for the number of vessels (+/-1), 98.3 % for ALC and 90 % for PVC. Inter-interpreter correlation (TV and MS) was 80 % for vessels (+/-1), 97.5 % for ALC and 83.3 % for PVC. CONCLUSION Our study demonstrates the feasibility of incorporating pCLE into clinical practice, demonstrating good diagnostic yield and reproducible outcomes in the screening of AR in lung transplant recipients.
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Affiliation(s)
- T Villeneuve
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France.
| | - C Hermant
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France
| | - A Le Borgne
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France
| | - M Murris
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France
| | - G Plat
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France
| | - V Héluain
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France
| | - M Colombat
- Cytology and Pathology Department, University Cancer Institute, Toulouse, France
| | - M Courtade-Saïdi
- Cytology and Pathology Department, University Cancer Institute, Toulouse, France
| | - S Evrard
- Cytology and Pathology Department, University Cancer Institute, Toulouse, France
| | - S Collot
- Radiology Department, Toulouse University Hospital, Toulouse, France
| | - M Salaün
- Respiratory Medicine Department, Department, Rouen University Hospital, Toulouse, France
| | - N Guibert
- Respiratory Medicine Department, Toulouse University Hospital, Toulouse, France
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6
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Gülşen M, Özçay F, Barış Z, Haberal M. Evaluation of Vitamin D Levels in Children With Liver Transplant. EXP CLIN TRANSPLANT 2024; 22:129-136. [PMID: 37486032 DOI: 10.6002/ect.2023.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVES Vitamin D deficiency is common in pediatric chronic liver disease despite oral replacement. We evaluated vitamin D deficiency before and after liver transplant and the relationship between posttransplant and pretransplant vitamin D deficiency and graft rejection. MATERIALS AND METHODS Pediatric recipients with chronic liver disease (N =138) were divided into 4 groups: cholestatic liver diseases, cirrhosis, metabolic disorders, and acute liver failure. Pretransplant and posttransplant vitamin D levels, liver function tests, Pediatric End-Stage Liver Disease scores, rejection activity index scores by graft liver biopsy, and posttransplant patient survival were recorded. RESULTS There were 62 (45%) female and 76 (55%) male participants (mean transplant age, 6.1 ± 5.6 years). Pretransplant mean available vitamin D of 90 patients was 25.2 ± 20.9 ng/mL, with 36 (40%) within reference range. Posttransplant level for 109 patients was 27.3 ± 18 ng/mL, with 64 (58.7%) within reference range. Pretransplant and posttransplant levels were available for 61 patients, and mean pretransplant levels were lower than posttransplant levels (23.7 ± 19.3 vs 28.3 ± 16.9 ng/mL; P = .01). Patients with cholestatic liver disease had lower pretransplant vitamin D levels (P = .04), which disappeared after transplant. Pretransplant vitamin D levels were positively correlated with serum albumin levels (r = 0.20) in all patients and negatively correlated with total/direct bilirubin (r = 0.29 and r = -0.30) in those with liver diseases and cirrhosis. No correlations were found between pretransplant vitamin D levels and Pediatric End-Stage Liver Disease scores, rejection activity index scores, and posttransplant mortality. CONCLUSIONS Vitamin D deficiency is prevalent in pediatric chronic liver disease before and after transplant, especially for cholestatic liver diseases. However, no association between vitamin D levels and liver graft rejection or patient survival was noted. We recommend close monitoring and individualized vitamin D supplementation before and after liver transplant.
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Affiliation(s)
- Murat Gülşen
- From the Department of Pediatrics, Etlik City Hospital, Ankara, Turkey
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7
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Cui Y, Lv Z, Yang Z, Lei J. Inhibition of Prostaglandin-Degrading Enzyme 15-PGDH Mitigates Acute Murine Lung Allograft Rejection. Lung 2023; 201:591-601. [PMID: 37934242 DOI: 10.1007/s00408-023-00651-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Acute rejection is a frequent complication among lung transplant recipients and poses substantial therapeutic challenges. 15-hydroxyprostaglandin dehydrogenase (15-PGDH), an enzyme responsible for the inactivation of prostaglandin E2 (PGE2), has recently been implicated in inflammatory lung diseases. However, the role of 15-PGDH in lung transplantation rejection remains elusive. The present study was undertaken to examine the expression of 15-PGDH in rejected lung allografts and whether inhibition of 15-PGDH ameliorates acute lung allograft rejection. METHODS Orthotopic mouse lung transplantations were performed between donor and recipient mice of the same strain or allogeneic mismatched pairs. The expression of 15-PGDH in mouse lung grafts was measured. The efficacy of a selective 15-PGDH inhibitor (SW033291) in ameliorating acute rejection was assessed through histopathological examination, micro-CT imaging, and pulmonary function tests. Additionally, the mechanism underlying the effects of SW033291 treatment was explored using CD8+ T cells isolated from mouse lung allografts. RESULTS Increased 15-PGDH expression was observed in rejected allografts and allogeneic CD8+ T cells. Treatment with SW033291 led to an accumulation of PGE2, modulation of CD8+ T-cell responses and mitochondrial activity, and improved allograft function and survival. CONCLUSION Our study provides new insights into the role of 15-PGDH in acute lung rejection and highlights the therapeutic potential of inhibiting 15-PGDH for enhancing graft survival. The accumulation of PGE2 and modulation of CD8+ T-cell responses represent potential mechanisms underlying the benefits of 15-PGDH inhibition in this model. Our findings provide impetus for further exploring 15-PGDH as a target for improving lung transplantation outcomes.
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Affiliation(s)
- Ye Cui
- Department of Immunology, School of Basic Medical Sciences, Capital Medical University, #10 Xi Tou Tiao, You An Men Wai, Fengtai, Beijing, 100069, People's Republic of China.
| | - Zhe Lv
- Department of Immunology, School of Basic Medical Sciences, Capital Medical University, #10 Xi Tou Tiao, You An Men Wai, Fengtai, Beijing, 100069, People's Republic of China
| | - Zeran Yang
- Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Jianfeng Lei
- Research Core Facilities, Capital Medical University, Beijing, 100069, People's Republic of China
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8
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Snyder ME, Anderson MR, Benvenuto LJ, Sutton RM, Bondonese A, Koshy R, Burke R, Clifford S, Craig A, Iasella CJ, Hannan SJ, Popescu I, Zhang Y, Sanchez PG, Alder JK, McDyer JF. Impact of age and telomere length on circulating T cells and rejection risk after lung transplantation for idiopathic pulmonary fibrosis. J Heart Lung Transplant 2023; 42:1666-1677. [PMID: 37544465 PMCID: PMC10839116 DOI: 10.1016/j.healun.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Most idiopathic pulmonary fibrosis (IPF) lung transplant recipients (IPF-LTRs) have short telomere (ST) length. Inherited mutations in telomere-related genes are associated with the development of T cell immunodeficiency. Despite this, IPF-LTRs with telomere-related rare variants are not protected from acute cellular rejection (ACR). We set out to determine the impact of both age and telomere length on the circulating T cell compartment and ACR burden of IPF-LTRs. METHODS We identified 106 IPF-LTRs who had telomere length testing using flowFISH (57 with short telomeres and 49 with long telomeres) as well as a subset from both cohorts who had cryopreserved PBMC at least 1 time point, 6 months posttransplantation. Circulating T cells from before transplantation and at 6 and 12 months posttransplantation were analyzed using multiparameter flow cytometry to study phenotype and functional capacity, and bulk T cell receptor sequencing was performed to study repertoire diversity. Linear regression was used to study the relationship of age and telomere length on early (within 1 year) and late (between 1 and 2 years) ACR. RESULTS IPF-LTRs with ST were found to have premature "aging" of their circulating T cell compartment, with age-agnostic elevations in posttransplant terminal differentiation of CD8+ T cells, increased granzyme B positivity of both CD8+ and CD4+ T cells, upregulation of the exhaustion marker, CD57, and chemotactic protein CCR5, and enhanced T cell receptor clonal expansion. Additionally, we found a significant decline in early ACR burden with increasing age, but only in the ST cohort. CONCLUSIONS IPF-LTRs with ST have premature "aging" of their circulating T cell compartment posttransplantation and a clear age-related decline in ACR burden.
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Affiliation(s)
- Mark E Snyder
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA; Starzl Transplantation Institute, Pittsburgh, Pennsylvania.
| | - Michaela R Anderson
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke J Benvenuto
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Rachel M Sutton
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anna Bondonese
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ritchie Koshy
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robin Burke
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah Clifford
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew Craig
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carlo J Iasella
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Pharmacology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stefanie J Hannan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Iulia Popescu
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yingze Zhang
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan K Alder
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John F McDyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Starzl Transplantation Institute, Pittsburgh, Pennsylvania.
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9
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Leung R, Lo WK, Sharma NS, Goldberg HJ, Chan WW. Esophageal Function and Reflux Evaluations in Lung Transplantation: A Nationwide Survey of UNOS-Accredited Transplant Centers in the United States. Clin Transl Gastroenterol 2023; 14:e00641. [PMID: 37747103 PMCID: PMC10749699 DOI: 10.14309/ctg.0000000000000641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION Gastroesophageal reflux disease has been associated with worse lung transplant outcomes. We aimed to assess local practices for esophageal function testing (EFT) across transplant centers. METHODS This was a survey study of all United Network for Organ Sharing-accredited adult lung transplant centers regarding local EFT practice. RESULTS Among 39/63 (60%) responded centers, 38.5% required any EFT (35.9% esophageal manometry, 15.4% pH monitoring, and 28.2% pH impedance), while another 28.2% may consider EFT based on symptoms. Five-year transplant volume was higher among centers requiring EFT (253 vs 159, P = 0.04). DISCUSSION Only a minority of lung transplant centers routinely obtained EFT, supporting the need for guidelines for standardized reflux/esophageal assessment.
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Affiliation(s)
- Ryan Leung
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nirmal S. Sharma
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hilary J. Goldberg
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W. Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Watanabe T, Juvet SC, Berra G, Havlin J, Zhong W, Boonstra K, Daigneault T, Horie M, Konoeda C, Teskey G, Guan Z, Hwang DM, Liu M, Keshavjee S, Martinu T. Donor IL-17 receptor A regulates LPS-potentiated acute and chronic murine lung allograft rejection. JCI Insight 2023; 8:e158002. [PMID: 37937643 PMCID: PMC10721268 DOI: 10.1172/jci.insight.158002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 09/15/2023] [Indexed: 11/09/2023] Open
Abstract
Chronic lung allograft dysfunction (CLAD) is a major complication after lung transplantation that results from a complex interplay of innate inflammatory and alloimmune factors, culminating in parenchymal and/or obliterative airway fibrosis. Excessive IL-17A signaling and chronic inflammation have been recognized as key factors in these pathological processes. Herein, we developed a model of repeated airway inflammation in mouse minor alloantigen-mismatched single-lung transplantation. Repeated intratracheal LPS instillations augmented pulmonary IL-17A expression. LPS also increased acute rejection, airway epithelial damage, and obliterative airway fibrosis, similar to human explanted lung allografts with antecedent episodes of airway infection. We then investigated the role of donor and recipient IL-17 receptor A (IL-17RA) in this context. Donor IL-17RA deficiency significantly attenuated acute rejection and CLAD features, whereas recipient IL-17RA deficiency only slightly reduced airway obliteration in LPS allografts. IL-17RA immunofluorescence positive staining was greater in human CLAD lungs compared with control human lung specimens, with localization to fibroblasts and myofibroblasts, which was also seen in mouse LPS allografts. Taken together, repeated airway inflammation after lung transplantation caused local airway epithelial damage, with persistent elevation of IL-17A and IL-17RA expression and particular involvement of IL-17RA on donor structural cells in development of fibrosis.
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Affiliation(s)
- Tatsuaki Watanabe
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Stephen C. Juvet
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Berra
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wenshan Zhong
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
| | - Kristen Boonstra
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
| | - Tina Daigneault
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
| | | | - Chihiro Konoeda
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Grace Teskey
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
| | - Zehong Guan
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
| | - David M. Hwang
- Department of Pathology, University Health Network, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Latner Thoracic Research Laboratories, University Health Network, Toronto, Ontario, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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11
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Cheon IS, Son YM, Sun J. Tissue-resident memory T cells and lung immunopathology. Immunol Rev 2023; 316:63-83. [PMID: 37014096 PMCID: PMC10524334 DOI: 10.1111/imr.13201] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/10/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
Rapid reaction to microbes invading mucosal tissues is key to protect the host against disease. Respiratory tissue-resident memory T (TRM ) cells provide superior immunity against pathogen infection and/or re-infection, due to their presence at the site of pathogen entry. However, there has been emerging evidence that exuberant TRM -cell responses contribute to the development of various chronic respiratory conditions including pulmonary sequelae post-acute viral infections. In this review, we have described the characteristics of respiratory TRM cells and processes underlying their development and maintenance. We have reviewed TRM -cell protective functions against various respiratory pathogens as well as their pathological activities in chronic lung conditions including post-viral pulmonary sequelae. Furthermore, we have discussed potential mechanisms regulating the pathological activity of TRM cells and proposed therapeutic strategies to alleviate TRM -cell-mediated lung immunopathology. We hope that this review provides insights toward the development of future vaccines or interventions that can harness the superior protective abilities of TRM cells, while minimizing the potential for immunopathology, a particularly important topic in the era of coronavirus disease 2019 (COVID-19) pandemic.
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Affiliation(s)
- In Su Cheon
- Carter Immunology Center, University of Virginia, Charlottesville, VA 22908, USA
- Division of Infectious Disease and International Health, Department of Medicine, University of Virginia, Charlottesville, VA 22908, USA
| | - Young Min Son
- Department of Systems Biotechnology, Chung-Ang University, Anseong, Gyeonggi-do, Republic of Korea 17546
| | - Jie Sun
- Carter Immunology Center, University of Virginia, Charlottesville, VA 22908, USA
- Division of Infectious Disease and International Health, Department of Medicine, University of Virginia, Charlottesville, VA 22908, USA
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12
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Beeckmans H, Bos S, Vos R, Glanville AR. Acute Rejection and Chronic Lung Allograft Dysfunction: Obstructive and Restrictive Allograft Dysfunction. Clin Chest Med 2023; 44:137-157. [PMID: 36774160 DOI: 10.1016/j.ccm.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation is an established treatment of well-selected patients with end-stage respiratory diseases. However, lung transplant recipients have the highest rates of acute and chronic rejection among transplanted solid organs. Owing to ongoing alloimmune recognition and associated immune-driven airway/vascular remodeling, precipitated by multifactorial, endogenous or exogenous, post-transplant injuries to the bronchovascular axis of the secondary pulmonary lobule, most lung transplant recipients will suffer from a pathophysiological decline of their allograft, either functionally and/or structurally. This review discusses current knowledge, barriers, and gaps in acute cellular rejection and chronic lung allograft dysfunction-the greatest impediment to long-term post-transplant survival.
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Affiliation(s)
- Hanne Beeckmans
- Department of Chronic Diseases and Metabolism, KU Leuven, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
| | - Saskia Bos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium; Newcastle University, Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Robin Vos
- Department of Chronic Diseases and Metabolism, KU Leuven, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium; Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.
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13
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Watanabe T, Lam C, Oliver J, Oishi H, Teskey G, Beber S, Boonstra K, Mauricio Umaña J, Buhari H, Joe B, Guan Z, Horie M, Keshavjee S, Martinu T, Juvet SC. Donor Batf3 inhibits murine lung allograft rejection and airway fibrosis. Mucosal Immunol 2023; 16:104-120. [PMID: 36842540 DOI: 10.1016/j.mucimm.2023.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 02/28/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) limits survival after lung transplantation. Noxious stimuli entering the airways foster CLAD development. Classical dendritic cells (cDCs) link innate and adaptive immunity and exhibit regional and functional specialization in the lung. The transcription factor basic leucine zipper ATF-like 3 (BATF3) is absolutely required for the development of type 1 cDCs (cDC1s), which reside in the airway epithelium and have variable responses depending on the context. We studied the role of BATF3 in a mouse minor alloantigen-mismatched orthotopic lung transplant model of CLAD with and without airway inflammation triggered by repeated administration of intratracheal lipopolysaccharide (LPS). We found that cDC1s accumulated in allografts compared with isografts and that donor cDC1s were gradually replaced by recipient cDC1s. LPS administration increased the number of cDC1s and enhanced their state of activation. We found that Batf3-/- recipient mice experienced reduced acute rejection in response to LPS; in contrast, Batf3-/- donor grafts underwent enhanced lung and skin allograft rejection and drove augmented recipient cluster of differentiation 8+ T-cell expansion in the absence of LPS. Our findings suggest that donor and recipient cDC1s have differing and context-dependent roles and may represent a therapeutic target in lung transplantation.
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Affiliation(s)
- Tatsuaki Watanabe
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada; Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Christina Lam
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Jillian Oliver
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Hisashi Oishi
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada; Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Grace Teskey
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Samuel Beber
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Kristen Boonstra
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Juan Mauricio Umaña
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Hifza Buhari
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Betty Joe
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Zehong Guan
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Miho Horie
- Joint Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Tereza Martinu
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada
| | - Stephen C Juvet
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Canada.
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14
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Markers of Bronchiolitis Obliterans Syndrome after Lung Transplant: Between Old Knowledge and Future Perspective. Biomedicines 2022; 10:biomedicines10123277. [PMID: 36552035 PMCID: PMC9775233 DOI: 10.3390/biomedicines10123277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/02/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) is the most common form of CLAD and is characterized by airflow limitation and an obstructive spirometric pattern without high-resolution computed tomography (HRCT) evidence of parenchymal opacities. Computed tomography and microCT analysis show abundant small airway obstruction, starting from the fifth generation of airway branching and affecting up to 40-70% of airways. The pathogenesis of BOS remains unclear. It is a multifactorial syndrome that leads to pathological tissue changes and clinical manifestations. Because BOS is associated with the worst long-term survival in LTx patients, many studies are focused on the early identification of BOS. Markers may be useful for diagnosis and for understanding the molecular and immunological mechanisms involved in the onset of BOS. Diagnostic and predictive markers of BOS have also been investigated in various biological materials, such as blood, BAL, lung tissue and extracellular vesicles. The aim of this review was to evaluate the scientific literature on markers of BOS after lung transplant. We performed a systematic review to find all available data on potential prognostic and diagnostic markers of BOS.
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15
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Bos S, Milross L, Filby AJ, Vos R, Fisher AJ. Immune processes in the pathogenesis of chronic lung allograft dysfunction: identifying the missing pieces of the puzzle. Eur Respir Rev 2022; 31:31/165/220060. [PMID: 35896274 DOI: 10.1183/16000617.0060-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Lung transplantation is the optimal treatment for selected patients with end-stage chronic lung diseases. However, chronic lung allograft dysfunction remains the leading obstacle to improved long-term outcomes. Traditionally, lung allograft rejection has been considered primarily as a manifestation of cellular immune responses. However, in reality, an array of complex, interacting and multifactorial mechanisms contribute to its emergence. Alloimmune-dependent mechanisms, including T-cell-mediated rejection and antibody-mediated rejection, as well as non-alloimmune injuries, have been implicated. Moreover, a role has emerged for autoimmune responses to lung self-antigens in the development of chronic graft injury. The aim of this review is to summarise the immune processes involved in the pathogenesis of chronic lung allograft dysfunction, with advanced insights into the role of innate immune pathways and crosstalk between innate and adaptive immunity, and to identify gaps in current knowledge.
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Affiliation(s)
- Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Luke Milross
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Andrew J Filby
- Flow Cytometry Core and Innovation, Methodology and Application Research Theme, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robin Vos
- Dept of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium.,University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
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16
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Jadcherla AV, Litzenberg K, Balasubramanian G. Esophageal Dysfunction in Post-lung Transplant: An Enigma. Dysphagia 2022; 38:731-743. [PMID: 35960395 DOI: 10.1007/s00455-022-10508-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.
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Affiliation(s)
| | - Kevin Litzenberg
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, Gastrointestinal Motility Laboratory, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd Floor, Columbus, OH, USA.
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17
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Erasmus DB, Durand N, Alvarez FA, Narula T, Hodge DO, Zubair AC. Feasibility and Safety of Low-Dose Mesenchymal Stem Cell Infusion in Lung Transplant Recipients. Stem Cells Transl Med 2022; 11:891-899. [PMID: 35881142 PMCID: PMC9492292 DOI: 10.1093/stcltm/szac051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background We have previously shown bone marrow-derived mesenchymal stem cells (MSCs) may shift immune responses toward anti-inflammatory pathways and stabilize the course of obstructive chronic lung allograft syndrome (o-CLAD) after lung transplantation. In this study, we measured the response of lower dose infusions. Methods We infused low-dose MSCs intravenously in 13 patients who had developed moderate-to-severe o-CLAD. Three had previously received an infusion of MSCs from a different donor and were re-dosed at 1 × 106 MSC/kg, while 5 received a first dose at 1 × 106 MSC/kg and five received an even lower dose at 0.5 × 106 MSC/kg. We recorded pulmonary function tests before and after infusion, and patients were followed clinically for 12 months. Results Infusions were well tolerated, and no significant adverse events were recorded in the first 30 days. There was significant decline (mean ± SD) in forced vital capacity (FVC) (3.49 ± 1.03 vs 3.18 ± 0.94 L, P = .03) and forced expiratory volume in 1 second (FEV1) (2.28 ± 0.86 vs 1.77 ± 0.49 L, P = .04) over the year preceding infusion. FVC (3.18 ± 0.94 vs 3.46 ± 0.99 L, P = .53) and FEV1 was not significantly changed (1.77 ± 0.49 vs 1.88 ± 0.75, P = .72) when comparing values immediately prior to infusion to those obtained 1 year after infusion, indicating a possible stabilizing effect on lung function decline due to o-CLAD. Conclusion Intravenous infusions of bone marrow-derived MSCs are well tolerated in lung transplant recipients with moderate-to-severe CLAD. Low-dose MSCs appear to slow progression of CLAD in some patients.
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18
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Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection (ACR), and antibody-mediated rejection (AMR) are risk factors for the subsequent development of chronic lung allograft dysfunction and worse outcomes after transplantation. Although ACR has well-defined histopathologic diagnostic criteria and grading, the diagnosis of AMR requires a multidisciplinary diagnostic approach. This article reviews the identification, clinical and pathologic features of, and therapeutic options for ACR and AMR.
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Affiliation(s)
- Deborah J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, 4523 Clayton Avenue, Mailstop 8052-0043-14, St Louis, MO 63110, USA.
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19
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Snyder ME, Moghbeli K, Bondonese A, Craig A, Popescu I, Fan L, Tabib T, Lafyatis R, Chen K, Trejo Bittar HE, Lendermon E, Pilewski J, Johnson B, Kilaru S, Zhang Y, Sanchez PG, Alder JK, Sims PA, McDyer JF. Modulation of tissue resident memory T cells by glucocorticoids after acute cellular rejection in lung transplantation. J Exp Med 2022; 219:e20212059. [PMID: 35285873 PMCID: PMC8924935 DOI: 10.1084/jem.20212059] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/13/2021] [Accepted: 02/04/2022] [Indexed: 01/01/2023] Open
Abstract
Acute cellular rejection is common after lung transplantation and is associated with an increased risk of early chronic rejection. We present combined single-cell RNA and TCR sequencing on recipient-derived T cells obtained from the bronchoalveolar lavage of three lung transplant recipients with rejection and compare them with T cells obtained from the same patients after treatment of rejection with high-dose systemic glucocorticoids. At the time of rejection, we found an oligoclonal expansion of cytotoxic CD8+ T cells that all persisted as tissue resident memory T cells after successful treatment. Persisting CD8+ allograft-resident T cells have reduced gene expression for cytotoxic mediators after therapy with glucocorticoids but accumulate around airways. This clonal expansion is discordant with circulating T cell clonal expansion at the time of rejection, suggesting in situ expansion. We thus highlight the accumulation of cytotoxic, recipient-derived tissue resident memory T cells within the lung allograft that persist despite the administration of high-dose systemic glucocorticoids. The long-term clinical consequences of this persistence have yet to be characterized.
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Affiliation(s)
- Mark E. Snyder
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
- Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Kaveh Moghbeli
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Anna Bondonese
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Andrew Craig
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Iulia Popescu
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Li Fan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Tracy Tabib
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Robert Lafyatis
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Kong Chen
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Joseph Pilewski
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce Johnson
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Silpa Kilaru
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yingze Zhang
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Peter A. Sims
- Department of Systems Biology, Columbia University Irving Medical Center, New York, NY
| | - John F. McDyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
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20
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Vyas S, Bansal A, Murugan N, Bhalla AS, Naranje P, Manchanda S. Hypersensitivity reactions and the respiratory system: Imaging based review. Curr Probl Diagn Radiol 2022; 52:56-65. [DOI: 10.1067/j.cpradiol.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/24/2022] [Accepted: 04/18/2022] [Indexed: 11/22/2022]
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21
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Habertheuer A, Ram C, Schmierer M, Chatterjee S, Hu R, Freas A, Zielinski P, Rogers W, Silvestro EM, McGrane M, Moore JS, Korutla L, Siddiqui S, Xin Y, Rizi R, Qin Tao J, Kreisel D, Naji A, Ochiya T, Vallabhajosyula P. Circulating Donor Lung-specific Exosome Profiles Enable Noninvasive Monitoring of Acute Rejection in a Rodent Orthotopic Lung Transplantation Model. Transplantation 2022; 106:754-766. [PMID: 33993180 DOI: 10.1097/tp.0000000000003820] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a critical need for development of biomarkers to noninvasively monitor for lung transplant rejection. We investigated the potential of circulating donor lung-specific exosome profiles for time-sensitive diagnosis of acute rejection in a rat orthotopic lung transplant model. METHODS Left lungs from Wistar transgenic rats expressing human CD63-GFP, an exosome marker, were transplanted into fully MHC-mismatched Lewis recipients or syngeneic controls. Recipient blood was collected between 4 h and 10 d after transplantation, and plasma was processed for exosome isolation by size exclusion column chromatography and ultracentrifugation. Circulating donor exosomes were profiled using antihuman CD63 antibody quantum dot on the nanoparticle detector and via GFP trigger on the nanoparticle flow cytometer. RESULTS In syngeneic controls, steady-state levels of circulating donor exosomes were detected at all posttransplant time points. Allogeneic grafts lost perfusion by day 8, consistent with acute rejection. Levels of circulating donor exosomes peaked on day 1, decreased significantly by day 2, and then reached baseline levels by day 3. Notably, decrease in peripheral donor exosome levels occurred before grafts had histological evidence of acute rejection. CONCLUSIONS Circulating donor lung-specific exosome profiles enable an early detection of acute rejection before histologic manifestation of injury to the pulmonary allograft. As acute rejection episodes are a major risk factor for the development of chronic lung allograft dysfunction, this biomarker may provide a novel noninvasive diagnostic platform that can translate into earlier therapeutic intervention for lung transplant patients.
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Affiliation(s)
- Andreas Habertheuer
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Chirag Ram
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Shampa Chatterjee
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robert Hu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrew Freas
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Patrick Zielinski
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Wade Rogers
- Still Pond Cytomics LLC, West Chester, PA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Eva M Silvestro
- Still Pond Cytomics LLC, West Chester, PA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Jonni S Moore
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Laxminarayana Korutla
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rahim Rizi
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jian Qin Tao
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Daniel Kreisel
- Departments of Surgery, Pathology & Immunology, Washington University, St. Louis, MI
| | - Ali Naji
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Takahiro Ochiya
- Department of Molecular and Cellular Medicine, Tokyo Medical University, Tokyo, Japan
| | - Prashanth Vallabhajosyula
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
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22
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Subramani MV, Pandit S, Gadre SK. Acute rejection and post lung transplant surveillance. Indian J Thorac Cardiovasc Surg 2022; 38:271-279. [PMID: 35340687 PMCID: PMC8938213 DOI: 10.1007/s12055-021-01320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose The purpose of this review is to summarize the current evidence on the evaluation and treatment of acute rejection after lung transplantation. Results Despite significant progress in the field of transplant immunology, acute rejection remains a frequent complication after transplantation. Almost 30% of lung transplant recipients experience at least one episode of acute cellular rejection (ACR) during the first year after transplant. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well-defined histopathologic diagnostic criteria and grading. The diagnosis of antibody-mediated rejection after lung transplantation requires a multidisciplinary approach. Antibody-mediated rejection may cause acute allograft failure. Conclusions Acute rejection is a risk factor for development of chronic rejection. Further investigations are required to better define risk factors, surveillance strategies, and optimal management strategies for acute allograft rejection.
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Affiliation(s)
| | - Sumir Pandit
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Shruti Kumar Gadre
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
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23
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Van Slambrouck J, Van Raemdonck D, Vos R, Vanluyten C, Vanstapel A, Prisciandaro E, Willems L, Orlitová M, Kaes J, Jin X, Jansen Y, Verleden GM, Neyrinck AP, Vanaudenaerde BM, Ceulemans LJ. A Focused Review on Primary Graft Dysfunction after Clinical Lung Transplantation: A Multilevel Syndrome. Cells 2022; 11:cells11040745. [PMID: 35203392 PMCID: PMC8870290 DOI: 10.3390/cells11040745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 02/01/2023] Open
Abstract
Primary graft dysfunction (PGD) is the clinical syndrome of acute lung injury after lung transplantation (LTx). However, PGD is an umbrella term that encompasses the ongoing pathophysiological and -biological mechanisms occurring in the lung grafts. Therefore, we aim to provide a focused review on the clinical, physiological, radiological, histological and cellular level of PGD. PGD is graded based on hypoxemia and chest X-ray (CXR) infiltrates. High-grade PGD is associated with inferior outcome after LTx. Lung edema is the main characteristic of PGD and alters pulmonary compliance, gas exchange and circulation. A conventional CXR provides a rough estimate of lung edema, while a chest computed tomography (CT) results in a more in-depth analysis. Macroscopically, interstitial and alveolar edema can be distinguished below the visceral lung surface. On the histological level, PGD correlates to a pattern of diffuse alveolar damage (DAD). At the cellular level, ischemia-reperfusion injury (IRI) is the main trigger for the disruption of the endothelial-epithelial alveolar barrier and inflammatory cascade. The multilevel approach integrating all PGD-related aspects results in a better understanding of acute lung failure after LTx, providing novel insights for future therapies.
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Affiliation(s)
- Jan Van Slambrouck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Dirk Van Raemdonck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Robin Vos
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Cedric Vanluyten
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Arno Vanstapel
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Pathology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Elena Prisciandaro
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Lynn Willems
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Pulmonary Circulation Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium;
| | - Michaela Orlitová
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.O.); (A.P.N.)
| | - Janne Kaes
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
| | - Xin Jin
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Yanina Jansen
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Geert M. Verleden
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Arne P. Neyrinck
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium; (M.O.); (A.P.N.)
- Department of Anesthesiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Bart M. Vanaudenaerde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
| | - Laurens J. Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.V.S.); (D.V.R.); (R.V.); (C.V.); (A.V.); (E.P.); (J.K.); (X.J.); (Y.J.); (G.M.V.); (B.M.V.)
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- Correspondence:
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24
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Hitz AM, Bläsing KA, Wiegmann B, Bellmàs-Sanz R, Chichelnitskiy E, Wandrer F, Horn LM, Neudörfl C, Keil J, Beushausen K, Ius F, Sommer W, Avsar M, Kühn C, Tudorache I, Salman J, Siemeni T, Haverich A, Warnecke G, Falk CS, Kühne JF. Donor NK and T Cells in the Periphery of Lung Transplant Recipients Contain High Frequencies of Killer Cell Immunoglobulin-Like Receptor-Positive Subsets. Front Immunol 2021; 12:778885. [PMID: 34966390 PMCID: PMC8710687 DOI: 10.3389/fimmu.2021.778885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/04/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction For end-stage lung diseases, double lung transplantation (DLTx) is the ultimate curative treatment option. However, acute and chronic rejection and chronic dysfunction are major limitations in thoracic transplantation medicine. Thus, a better understanding of the contribution of immune responses early after DLTx is urgently needed. Passenger cells, derived from donor lungs and migrating into the recipient periphery, are comprised primarily by NK and T cells. Here, we aimed at characterizing the expression of killer cell immunoglobulin-like receptors (KIR) on donor and recipient NK and T cells in recipient blood after DLTx. Furthermore, we investigated the functional status and capacity of donor vs. recipient NK cells. Methods Peripheral blood samples of 51 DLTx recipients were analyzed pre Tx and at T0, T24 and 3wk post Tx for the presence of HLA-mismatched donor NK and T cells, their KIR repertoire as well as activation status using flow cytometry. Results Within the first 3 weeks after DLTx, donor NK and T cells were detected in all patients with a peak at T0. An increase of the KIR2DL/S1-positive subset was found within the donor NK cell repertoire. Moreover, donor NK cells showed significantly higher frequencies of KIR2DL/S1-positive cells (p<0.01) 3wk post DLTx compared to recipient NK cells. This effect was also observed in donor KIR+ T cells 3wk after DLTx with higher proportions of KIR2DL/S1 (p<0.05) and KIR3DL/S1 (p<0.01) positive T cells. Higher activation levels of donor NK and T cells (p<0.001) were detected compared to recipient cells via CD25 expression as well as a higher degranulation capacity upon activation by K562 target cells. Conclusion Higher frequencies of donor NK and T cells expressing KIR compared to recipient NK and T cells argue for their origin in the lung as a part of a highly specialized immunocompetent compartment. Despite KIR expression, higher activation levels of donor NK and T cells in the periphery of recipients suggest their pre-activation during the ex situ phase. Taken together, donor NK and T cells are likely to have a regulatory effect in the balance between tolerance and rejection and, hence, graft survival after DLTx.
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Affiliation(s)
- Anna-Maria Hitz
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Kim-Alina Bläsing
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Bettina Wiegmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, DZL, BREATH Site, Hannover, Germany
| | - Ramon Bellmàs-Sanz
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | | | - Franziska Wandrer
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Lisa-Marie Horn
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Christine Neudörfl
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Jana Keil
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Kerstin Beushausen
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic Surgery, University Hospital Jena, Jena, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, DZL, BREATH Site, Hannover, Germany.,German Center for Infection Research, DZIF, TTU-IICH, Hannover-Braunschweig, Germany
| | - Jenny F Kühne
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
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Abstract
PURPOSE OF REVIEW To explore the role of upper gastrointestinal disease in the clinical course of lung transplant patients - including its pathophysiology, diagnostic testing, and treatment options. RECENT FINDINGS Gastroesophageal reflux disease (GERD) and foregut motility disorders are more prevalent among end-stage lung disease patients and are associated with poorer outcomes in lung transplant recipients. A proposed mechanism is the exposure of the lung allograft to aspirated contents, resulting in inflammation and rejection. Diagnostic tools to assess for these disorders include multichannel intraluminal impedance and pH (MII-pH) testing, high resolution esophageal manometry (HREM), and gastric emptying scintigraphy. The main treatment options are medical management with acid suppressants and/or prokinetic agents and anti-reflux surgery. In particular, data support the use of early anti-reflux surgery to improve outcomes. Newer diagnostic tools such as MII-pH testing and HREM allow for the identification of both acid and non-acid reflux and esophageal motility disorders, respectively. Recent studies have demonstrated that early anti-reflux surgery within six months post-transplant better protects against allograft injury and pulmonary function decline when compared to late surgery. However, further prospective research is needed to evaluate the short and long-term outcomes of these diagnostic approaches and interventions.
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DeFreitas MR, McAdams HP, Azfar Ali H, Iranmanesh AM, Chalian H. Complications of Lung Transplantation: Update on Imaging Manifestations and Management. Radiol Cardiothorac Imaging 2021; 3:e190252. [PMID: 34505059 DOI: 10.1148/ryct.2021190252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 12/23/2022]
Abstract
As lung transplantation has become the most effective definitive treatment option for end-stage chronic respiratory diseases, yearly rates of this surgery have been steadily increasing. Despite improvement in surgical techniques and medical management of transplant recipients, complications from lung transplantation are a major cause of morbidity and mortality. Some of these complications can be classified on the basis of the time they typically occur after lung transplantation, while others may occur at any time. Imaging studies, in conjunction with clinical and laboratory evaluation, are key components in diagnosing and monitoring these conditions. Therefore, radiologists play a critical role in recognizing and communicating findings suggestive of lung transplantation complications. A description of imaging features of the most common lung transplantation complications, including surgical, medical, immunologic, and infectious complications, as well as an update on their management, will be reviewed here. Keywords: Pulmonary, Thorax, Surgery, Transplantation Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Mariana R DeFreitas
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Holman Page McAdams
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Hakim Azfar Ali
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Arya M Iranmanesh
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
| | - Hamid Chalian
- Department of Radiology, Division of Cardiothoracic Imaging (M.R.D., H.P.M., A.M.I., H.C.), and Department of Medicine, Division of Pulmonary, Allergy and Critical Care (H.A.A.), Duke University Medical Center, Durham, NC
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27
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Desensitization and management of allograft rejection. Curr Opin Organ Transplant 2021; 26:314-320. [PMID: 33938468 DOI: 10.1097/mot.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) limits the success of lung transplantation. Among the risk factors associated with CLAD, we recognize pretransplant circulating antibodies against the human leukocyte antigens (HLA), acute cellular rejection (ACR) and antibody-mediated rejection (AMR). This review will summarize current data surrounding management of desensitization, ACR, AMR, and CLAD. RECENT FINDINGS Strategies in managing in highly sensitized patients waiting for lung transplant include avoidance of specific HLA antigens and reduction of circulating anti-HLA antibodies at time of transplant. Several multimodal approaches have been studied in the treatment of AMR with a goal to clear circulating donor-specific antibodies (DSAs) and to halt the production of new antibodies. Different immunosuppressive strategies focus on influence of the host immune system, particularly T-cell responses, in order to prevent ACR and the progression of CLAD. SUMMARY The lack of significant evidence and consensus limits to draw conclusion regarding the impact of specific immunosuppressive regimens in the management of HLA antibodies, ACR, and CLAD. Development of novel therapeutic agents and use of multicenter randomized clinical trials will allow to better define patient-specific treatments and improve the length and quality of life of lung transplant recipients.
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Ball AL, Edge RJ, Amin K, Critchley WR, Howell GJ, Yonan N, Stone JP, Fildes JE. A post-preservation vascular flush removes significant populations of donor leukocytes prior to lung transplantation. Transpl Immunol 2020; 64:101356. [PMID: 33264679 DOI: 10.1016/j.trim.2020.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/30/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Donor leukocytes are intrinsically involved in acute lung allograft rejection, via self-presentation of donor antigens to recipient leukocytes. Therapeutic modalities to remove donor leukocytes are currently unavailable. We evaluated if a vascular flush immediately following preservation can be used for this purpose. METHODS A post-preservation flush was performed with STEEN solution in n = 6 porcine lungs following static cold storage. The first 500 ml effluent from the left atrium was collected and an inflammatory profile performed. RESULTS A total of 1.17 billion (±2.8 × 108) viable leukocytes were identified within the effluent. T cells were the dominant cell population, representing 82% of the total mobilised leukocytes, of which <0.01% were regulatory T cells. IL-18 was the most abundant cytokine, with a mean concentration of 84,216 pg (±153,552 pg). In addition, there was a mean concentration of 8819 ng (±4415) cell-free mitochondrial DNA. CONCLUSION There is an immediate transfer of donor leukocytes, cytokines and damage-associated molecular patterns following reperfusion. Such a pro-inflammatory donor load may enhance alloantigen presentation and drive recipient alloimmune responses. A post-preservation flush may therefore be an effective method for reducing the immune burden of the donor lung prior to transplantation.
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Affiliation(s)
- Alexandra L Ball
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom; The Ex-Vivo Lab, Division of Cell Matrix and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom
| | - Rebecca J Edge
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom; The Ex-Vivo Lab, Division of Cell Matrix and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom
| | - Kavit Amin
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom; The Ex-Vivo Lab, Division of Cell Matrix and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom
| | - William R Critchley
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom; The Ex-Vivo Lab, Division of Cell Matrix and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom
| | - Gareth J Howell
- Flow Cytometry Core Facility, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom
| | - Nizar Yonan
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom
| | - John P Stone
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom; The Ex-Vivo Lab, Division of Cell Matrix and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom
| | - James E Fildes
- The Transplant Centre, University of Manchester NHS Foundation Trust, Manchester M23 9LT, United Kingdom; The Ex-Vivo Lab, Division of Cell Matrix and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, United Kingdom.
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Mohseni MM, Li Z, Simon LV. Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience. J Emerg Med 2020; 60:150-157. [PMID: 33158689 DOI: 10.1016/j.jemermed.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/02/2020] [Accepted: 10/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Emergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature. OBJECTIVES To analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment. METHODS This was a retrospective cohort study of LT patients at our ED (2015-2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death. RESULTS For 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n = 152, 30.1%). Infection was the most common ED diagnosis (n = 101, 20.0%). Many patients were sent home from the ED (n = 235, 46.5%), and 31.3% (n = 158) returned to the ED within 30 days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90 mm Hg were significantly associated with ICU admission or death. CONCLUSION Infection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30 days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.
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Affiliation(s)
- Michael M Mohseni
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
| | - Zhuo Li
- Biostatistics Unit, Mayo Clinic, Jacksonville, Florida
| | - Leslie V Simon
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
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30
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Metwally AA, Ascoli C, Turturice B, Rani A, Ranjan R, Chen Y, Schott C, Faro A, Ferkol TW, Finn PW, Perkins DL. Pediatric lung transplantation: Dynamics of the microbiome and bronchiolitis obliterans in cystic fibrosis. J Heart Lung Transplant 2020; 39:824-834. [PMID: 32580896 DOI: 10.1016/j.healun.2020.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 04/02/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Compositional changes in the microbiome are associated with the development of bronchiolitis obliterans (BO) after lung transplantation (LTx) in adults with cystic fibrosis (CF). The association between the lower airway bacterial community and BO after LTx in children with CF remains largely unexplored and is possibly influenced by frequent antibiotic therapy. The objectives of this study were to examine the relationship between bacterial community dynamics and the development of BO and analyze antibiotic resistance trends in children after LTx for CF. METHODS For 3 years from the time of transplant, 12 LTx recipients were followed longitudinally, with 5 subjects developing BO during the study period. A total of 82 longitudinal bronchoalveolar lavage samples were collected during standard of care bronchoscopies. Metagenomic shotgun sequencing was performed on the extracted microbial DNA from bronchoalveolar lavage specimens. Taxonomic profiling was constructed using WEVOTE pipeline. The longitudinal association between development of BO and temporal changes in bacterial diversity and abundance were evaluated with MetaLonDA. The analysis of antibiotic resistance genes was performed with the ARGs-OAP v2.0 pipeline. RESULTS All recipients demonstrated a Proteobacteria-predominant lower airways community. Temporal reduction in bacterial diversity was significantly associated with the development of BO and associated with neutrophilia and antibiotic therapy. Conversely, an increasing abundance of the phylum Actinobacteria and the orders Neisseriales and Pseudonocardiales in the lower airways was significantly associated with resilience to BO. A more diverse bacterial community was related to a higher expression of multidrug resistance genes and increased proteobacterial abundance. CONCLUSIONS Decreased diversity within bacterial communities may suggest a contribution to pediatric lung allograft rejection in CF.
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Affiliation(s)
- Ahmed A Metwally
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois; Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Department of Genetics, Stanford University, Stanford, California
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Benjamin Turturice
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Departments of Microbiology and Immunology
| | - Asha Rani
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Ravi Ranjan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Yang Chen
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Biological Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Cody Schott
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Departments of Microbiology and Immunology
| | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland; Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas W Ferkol
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri; Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri
| | - Patricia W Finn
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois; Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Departments of Microbiology and Immunology.
| | - David L Perkins
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois; Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Department of Surgery, University of Illinois at Chicago, Chicago, Illinois.
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31
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Greer M, Werlein C, Jonigk D. Surveillance for acute cellular rejection after lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:410. [PMID: 32355854 PMCID: PMC7186718 DOI: 10.21037/atm.2020.02.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute cellular rejection (ACR) is a common complication following lung transplantation (LTx), affecting almost a third of recipients in the first year. Established, comprehensive diagnostic criteria exist but they necessitate allograft biopsies which in turn increases clinical risk and can pose certain logistical and economic problems in service delivery. Undermining these challenges further, are known problems with inter-observer interpretation of biopsies and uncertainty as to the long-term implications of milder or indeed asymptomatic episodes. Increased risk of chronic lung allograft dysfunction (CLAD) has long been considered the most significant consequence of ACR. Consensus is lacking as to whether this applies to mild ACR, with contradictory evidence available. Given these issues, research into alternative, minimal or non-invasive biomarkers represents the main focus of research in ACR. A number of potential markers have been proposed, but none to date have demonstrated adequate sensitivity and specificity to allow translation from bench to bedside.
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Affiliation(s)
- Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany
| | | | - Danny Jonigk
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany.,Institute for Pathology, Hannover Medical School, Hannover, Germany
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32
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Kalucka J, de Rooij LP, Goveia J, Rohlenova K, Dumas SJ, Meta E, Conchinha NV, Taverna F, Teuwen LA, Veys K, García-Caballero M, Khan S, Geldhof V, Sokol L, Chen R, Treps L, Borri M, de Zeeuw P, Dubois C, Karakach TK, Falkenberg KD, Parys M, Yin X, Vinckier S, Du Y, Fenton RA, Schoonjans L, Dewerchin M, Eelen G, Thienpont B, Lin L, Bolund L, Li X, Luo Y, Carmeliet P. Single-Cell Transcriptome Atlas of Murine Endothelial Cells. Cell 2020; 180:764-779.e20. [DOI: 10.1016/j.cell.2020.01.015] [Citation(s) in RCA: 284] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/21/2019] [Accepted: 01/09/2020] [Indexed: 12/29/2022]
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33
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Bin Saeedan M, Mukhopadhyay S, Lane CR, Renapurkar RD. Imaging indications and findings in evaluation of lung transplant graft dysfunction and rejection. Insights Imaging 2020; 11:2. [PMID: 31900671 PMCID: PMC6942098 DOI: 10.1186/s13244-019-0822-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/29/2019] [Indexed: 11/16/2022] Open
Abstract
Lung transplantation is a treatment option in end-stage lung disease. Complications can develop along a continuum in the immediate or longer post-transplant period, including surgical and technical complications, primary graft dysfunction, rejection, infections, post-transplant lymphoproliferative disorder, and recurrence of the primary disease. These complications have overlapping clinical and imaging features and often co-exist. Time of onset after transplant is helpful in narrowing the differential diagnosis. In the early post transplantation period, imaging findings are non-specific and need to be interpreted in the context of the clinical picture and other investigations. In contrast, imaging plays a key role in diagnosing and monitoring patients with chronic lung allograft dysfunction. The goal of this article is to review primary graft dysfunction, acute rejection, and chronic rejection with emphasis on the role of imaging, pathology findings, and differential diagnosis.
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Affiliation(s)
- Mnahi Bin Saeedan
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, L-10, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | | | - C Randall Lane
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, USA
| | - Rahul D Renapurkar
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, L-10, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Watanabe T, Martinu T, Chruscinski A, Boonstra K, Joe B, Horie M, Guan Z, Bei KF, Hwang DM, Liu M, Keshavjee S, Juvet SC. A B cell-dependent pathway drives chronic lung allograft rejection after ischemia-reperfusion injury in mice. Am J Transplant 2019; 19:3377-3389. [PMID: 31365766 DOI: 10.1111/ajt.15550] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) limits long-term survival after lung transplant (LT). Ischemia-reperfusion injury (IRI) promotes chronic rejection (CR) and CLAD, but the underlying mechanisms are not well understood. To examine mechanisms linking IRI to CR, a mouse orthotopic LT model using a minor alloantigen strain mismatch (C57BL/10 [B10, H-2b ] → C57BL/6 [B6, H-2b ]) and isograft controls (B6→B6) was used with antecedent minimal or prolonged graft storage. The latter resulted in IRI with subsequent airway and parenchymal fibrosis in prolonged storage allografts but not isografts. This pattern of CR after IRI was associated with the formation of B cell-rich tertiary lymphoid organs within the grafts and circulating autoantibodies. These processes were attenuated by B cell depletion, despite preservation of allograft T cell content. Our observations suggest that IRI may promote B cell recruitment that drives CR after LT. These observations have implications for the mechanisms leading to CLAD after LT.
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Affiliation(s)
- Tatsuaki Watanabe
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrzej Chruscinski
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Kristen Boonstra
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Betty Joe
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Miho Horie
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Zehong Guan
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ke Fan Bei
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David M Hwang
- Department of Laboratory Medicine and Pathobiology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C Juvet
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Parulekar AD, Kao CC. Detection, classification, and management of rejection after lung transplantation. J Thorac Dis 2019; 11:S1732-S1739. [PMID: 31632750 DOI: 10.21037/jtd.2019.03.83] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well defined histopathologic diagnostic criteria and grading. Diagnosis of AMR requires a multidisciplinary approach. CLAD is the major barrier to long-term survival following lung transplantation. The most common phenotype of CLAD is bronchiolitis obliterans syndrome (BOS) which is defined by a persistent obstructive decline in lung function. Restrictive allograft dysfunction (RAS) is a second phenotype of CLAD and is associated with a worse prognosis. This article will review the diagnosis, staging, clinical presentation, and treatment of acute rejection, AMR, and CLAD following lung transplantation.
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Affiliation(s)
- Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Diagnosis of Acute Cellular Rejection Using Probe-based Confocal Laser Endomicroscopy in Lung Transplant Recipients: A Prospective, Multicenter Trial. Transplantation 2019; 103:428-434. [PMID: 29847505 DOI: 10.1097/tp.0000000000002306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute cellular rejection (ACR) in lung transplant recipients requires demonstration of perivascular lymphocytic infiltration in alveolar tissue samples from transbronchial biopsies (TBBs). Probe-based confocal laser endomicroscopy (pCLE) allows in vivo observation of alveolar, vascular, and cellular microstructures in the lung with potential to identify ACR. The objective of our prospective, blinded, multicenter observational study was to identify pCLE findings in patients with ACR diagnosed histopathologically by TBB. METHODS Lung transplant recipients undergoing diagnostic bronchoscopies within 1 year posttransplant for suspected ACR had pCLE video imaging obtained immediately prior to tissue sampling via TBB. Findings of 2 pCLE criteria, abundant alveolar cellularity and perivascular cellularity (PVC), were assessed by 4 investigators familiar with pCLE and compared with histopathologic criteria of ACR to derive sensitivity, specificity, area under the receiver operating characteristic curve, and accuracy. Interobserver agreement was assessed by calculating intraclass coefficient and Fleiss κ. Findings were analyzed before and after a consensus meeting of investigators on interpreting images. RESULTS Thirty pCLE procedures were performed on 24 patients, 8 showing ACR in TBB. Diagnostic performance and interobserver agreement using pCLE to identify PVC were significantly higher than those of abundant alveolar cellularity (P < 0.01). The number of blood vessels identified with PVC on pCLE was significantly correlated with histopathologic activity grading of ACR (P < 0.01). Perivascular cellularity agreement among investigators significantly improved after consensus meeting (P < 0.01). CONCLUSIONS When found on pCLE, PVC is a feasible and reproducible criterion for assessment of ACR in vivo, but there is a learning curve for image interpretation.
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Siddiqui S, Habertheuer A, Xin Y, Pourfathi M, Tao JQ, Hamedani H, Kadlecek S, Duncan I, Vallabhajosyula P, Naji A, Chatterjee S, Rizi R. Detection of lung transplant rejection in a rat model using hyperpolarized [1- 13 C] pyruvate-based metabolic imaging. NMR IN BIOMEDICINE 2019; 32:e4107. [PMID: 31112351 PMCID: PMC6620127 DOI: 10.1002/nbm.4107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/19/2019] [Accepted: 03/29/2019] [Indexed: 05/03/2023]
Abstract
The current standard for noninvasive imaging of acute rejection consists of X-ray/CT, which derive their contrast from changes in ventilation, inflammation and edema, as well as remodeling during rejection. We propose the use of hyperpolarized [1-13 C] pyruvate MRI-which provides real-time metabolic assessment of tissue-as an early biomarker for tissue rejection. In this preliminary study, we used μCT-derived parameters and HP 13 C MR-derived biomarkers to predict rejection in an orthotopic left lung transplant model in both allogeneic and syngeneic rats. On day 3, the normalized lung density-a parameter that accounts for both lung volume (mL) and density (HU)-was -0.335 (CI: -0.598, -0.073) and - 0.473 (CI: -0.726, -0.220) for the allograft and isograft, respectively (not significant, 0.40). The lactate-to-pyruvate ratios-derived from the HP 13 C MRI-for the allograft and isograft were 0.200 (CI: 0.161, 0.240) and 0.114 (CI: 0.074, 0.153), respectively (significant, 0.020). Both techniques showed tissue rejection on day 7. A separate sub-study revealed CD8+ cells as the primary source of the lactate-to-pyruvate signal. Our study suggests that hyperpolarized (HP) [1-13 C] pyruvate MRI is a promising early biomarker for tissue rejection that provides metabolic assessment in real time based on changes in cellularity and metabolism of lung tissue and the infiltrating inflammatory cells, and may be able to predict tissue rejection earlier than X-ray/CT.
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Affiliation(s)
- Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Yi Xin
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Jian-quin Tao
- Institute for Environmental Medicine, University of Pennsylvania, PA, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Ian Duncan
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Ali Naji
- Department of Surgery, University of Pennsylvania, PA, USA
| | - Shampa Chatterjee
- Institute for Environmental Medicine, University of Pennsylvania, PA, USA
| | - Rahim Rizi
- Department of Radiology, University of Pennsylvania, PA, USA
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Acute cellular rejection in lung transplantation. Afr J Thorac Crit Care Med 2019; 25. [PMID: 34286249 PMCID: PMC8278989 DOI: 10.7196/ajtccm.2019.v25i2.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 11/08/2022] Open
Abstract
Lung transplantation is an important therapy for end-stage respiratory failure in patients who have exhausted other therapeutic options. The lung is unique among solid-organ transplants in that it is exposed to the outside environment, and undergoes continuous stimulation from infectious and non-infectious agents, which may play a part in upregulating the immune response to the allograft. Despite induction immunosuppression and the use of aggressive maintenance regimens, acute allograft rejection is still a major problem, especially in the first year after transplant, with important diagnostic and therapeutic challenges. As well as being responsible for early graft failure and death, acute rejection also initiates alloimmune responses that predispose patients to chronic lung allograft dysfunction, in particular bronchiolitis obliterans syndrome. Cellular responses to human leukocyte antigens (HLAs) on the allograft have traditionally been considered the main mechanism of acute rejection, although the influence of humoral immunity is increasingly recognised. Here, we present two cases of acute cellular rejection (ACR) in the early post-transplant period and review the pathophysiology, diagnosis, clinical presentation and treatment of ACR.
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Aversa M, Benvenuto L, Kim H, Shah L, Robbins H, Stanifer BP, D'Ovidio F, Vasilescu ERR, Sonett J, Arcasoy SM. Effect of Calculated Panel Reactive Antibody Value on Waitlist Outcomes for Lung Transplant Candidates. Ann Transplant 2019; 24:383-392. [PMID: 31249284 PMCID: PMC6621645 DOI: 10.12659/aot.915769] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background We conducted a retrospective cohort study using United Network of Organ Sharing (UNOS) data to determine the effect of the calculated panel reactive antibody (cPRA) value on waitlist outcomes for lung transplant candidates. Material/Methods We divided lung transplant candidates into groups based on their cPRA value at the time of waitlist activation (0–25%, 25.1–50%, 50.1–75%, and 75.1–100%) and compared each group’s waitlist outcomes to the lowest quartile (“minimally sensitized”) group. The primary outcome was lung transplantation and the secondary outcome was waitlist mortality (a composite of death on the waitlist/delisting for clinical deterioration). Results Compared to the minimally sensitized group, candidates with a cPRA value of 25.1–50% did not have a significantly different likelihood of undergoing lung transplant or waitlist mortality, candidates with a cPRA value of 50.1–75% were 25% less likely to undergo lung transplant and 44% more likely to die on the waitlist, and candidates with a cPRA value of 75.1–100% were 52% less likely to undergo lung transplant and 92% more likely to die on the waitlist. Conclusions CPRA values of greater than 50% are associated with significantly lower rates of transplantation and higher waitlist mortality.
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Affiliation(s)
- Meghan Aversa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York City, NY, USA
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York City, NY, USA
| | - Hanyoung Kim
- New York-Presbyterian Hospital, New York City, NY, USA
| | - Lori Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York City, NY, USA
| | - Hilary Robbins
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York City, NY, USA
| | - B Payne Stanifer
- Division of Thoracic Surgery, Department of Surgery, Columbia University Medical Center, New York City, NY, USA
| | - Frank D'Ovidio
- Division of Thoracic Surgery, Department of Surgery, Columbia University Medical Center, New York City, NY, USA
| | - Elena-Rodica R Vasilescu
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York City, NY, USA
| | - Joshua Sonett
- Division of Thoracic Surgery, Department of Surgery, Columbia University Medical Center, New York City, NY, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York City, NY, USA
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Law N, Hamandi B, Fegbeutel C, Silveira FP, Verschuuren EA, Ussetti P, Chin-Hong PV, Sole A, Holmes-Liew CL, Billaud EM, Grossi PA, Manuel O, Levine DJ, Barbers RG, Hadjiliadis D, Younus M, Aram J, Chaparro C, Singer LG, Husain S. Lack of association of Aspergillus colonization with the development of bronchiolitis obliterans syndrome in lung transplant recipients: An international cohort study. J Heart Lung Transplant 2019; 38:963-971. [PMID: 31300191 DOI: 10.1016/j.healun.2019.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/30/2019] [Accepted: 06/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a major limitation in the long-term survival of lung transplant recipients (LTRs). However, the risk factors in the development of BOS remain undetermined. We conducted an international cohort study of LTRs to assess whether Aspergillus colonization with large or small conidia is a risk factor for the development of BOS. METHODS Consecutive LTRs from January 2005 to December 2008 were evaluated. Rates of BOS and associated risk factors were recorded at 4 years. International Society of Heart and Lung Transplantation criteria were used to define fungal and other infections. A Cox proportional-hazards-model was constructed to assess the association between Aspergillus colonization and the development of BOS controlling for confounders. RESULTS A total of 747 LTRs were included. The cumulative incidence of BOS at 4 years after transplant was 33% (250 of 747). Additionally, 22% of LTRs experienced Aspergillus colonization after transplantation. Aspergillus colonization with either large (hazard ratio [HR] = 0.6, 95% confidence interval [CI] = 0.3-1.2, p = 0.12) or small conidia (HR = 0.9, 95% CI = 0.6-1.4, p = 0.74) was not associated with the development of BOS. Factors associated with increased risk of development of BOS were the male gender (HR = 1.4, 95% CI = 1.1-1.8, p = 0.02) and episodes of acute rejection (1-2 episodes, HR = 1.5, 95% CI = 1.1-2.1, p = 0.014; 3-4 episodes, HR = 1.6, 95% CI = 1.0-2.6, p = 0.036; >4 episodes, HR = 2.2, 95% CI = 1.1-4.3, p = 0.02), whereas tacrolimus use was associated with reduced risk of BOS (HR = 0.6, 95% CI = 0.5-0.9, p = 0.007). CONCLUSIONS We conclude from this large multicenter cohort of lung transplant patients, that Aspergillus colonization with large or small conidia did not show an association with the development of BOS.
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Affiliation(s)
- Nancy Law
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Bassem Hamandi
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Christine Fegbeutel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Fernanda P Silveira
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Erik A Verschuuren
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, Groningen, The Netherlands
| | - Piedad Ussetti
- Respiratory Department, Hospital Puerta di Hierro, Madrid, Spain
| | - Peter V Chin-Hong
- Department of Medicine, University of California, San Francisco, California, USA
| | - Amparo Sole
- Respiratory Department, University and Polytechnic Hospital La Fe, Universidad de Valencia, Valencia, Spain
| | - Chien-Li Holmes-Liew
- Lung Research, Hanson Institute and Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eliane M Billaud
- Service de Pharmacologie, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | - Paolo A Grossi
- Department of Infectious Diseases, University of Insubria, Varese, Italy
| | - Oriol Manuel
- Transplantation Center and Infectious Diseases Service, University Hospital of Lausanne, Lausanne, Switzerland
| | - Deborah J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Richard G Barbers
- Division of Pulmonary and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Denis Hadjiliadis
- Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jay Aram
- Pfizer Incorporated, New York, New York, USA
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada.
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Darley DR, Carlos L, Hennig S, Liu Z, Day R, Glanville AR. Tacrolimus exposure early after lung transplantation and exploratory associations with acute cellular rejection. Eur J Clin Pharmacol 2019; 75:879-888. [PMID: 30859243 DOI: 10.1007/s00228-019-02658-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 02/27/2019] [Indexed: 12/18/2022]
Abstract
AIMS To (i) describe tacrolimus (TAC) pre-dose concentrations (C0), (ii) calculate apparent oral TAC clearance (CL/FHCT) adjusted for measured haematocrit (HCTi) and standardised to a HCT of 45%, across three observation time points and (iii) explore if low TAC C0 or high mean CL/FHCT are associated with an increased risk of rejection episodes early after lung transplantation. METHODS TAC whole blood concentration-time profiles and transbronchial biopsies were performed prospectively at weeks 3, 6 and 12 after lung transplantation. The TAC pre-dose concentration (C0) was measured, and CL/FHCT was determined using non-compartmental analysis. The associations between TAC C0 and CL/FHCT and rejection status were explored using repeated measures logistic regression. RESULTS Eighteen patients provided 377 TAC whole blood concentrations. Considerable variability around the median (IQR) CL/FHCT 6.8 (4.2-15.9) L h-1, and the median C0 12.7 (9.9-16.6) μg L-1 was noted. Despite adjustment for haematocrit, a significant decrease was observed in CL/FHCT in all patients over time: CL/FHCT 14 (5.4-23) at week 3, CL/FHCT 7.7 (4.5-12) at week 6 and CL/FHCT 3.9 (2.4-11) L h-1 at week 12 (p < 0.01). Seven (38.9%) patients experienced a single grade 2 rejection, whilst 11 (61.1%) patients experienced no rejection. Higher TAC C0 were associated with a reduced risk of rejection OR 0.68 (95% CI 0.51-0.91, p = 0.02), and greater mean CL/FHCT was associated with an increased risk of rejection OR 1.34 (95% CI 1.01-1.81 p = 0.04). CONCLUSION Monitoring TAC C0, HCT and CL/FHCT in patients after lung transplantation may assist clinicians in detecting patients at risk of acute rejection and may guide future research into TAC and HCT monitoring after lung transplantation.
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Affiliation(s)
- David R Darley
- Lung Transplant Unit, St Vincent's Hospital Darlinghurst, Sydney, Australia. .,UNSW Medicine, St Vincent's Hospital Clinical School, Sydney, Australia.
| | - Lilibeth Carlos
- Department of Pharmacy, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Stefanie Hennig
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Zhixin Liu
- Department of Statistics, University of New South Wales, Kensington, Australia
| | - Richard Day
- UNSW Medicine, St Vincent's Hospital Clinical School, Sydney, Australia.,Department of Clinical Pharmacology, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Allan R Glanville
- Lung Transplant Unit, St Vincent's Hospital Darlinghurst, Sydney, Australia
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Role of Mast Cells and Type 2 Innate Lymphoid (ILC2) Cells in Lung Transplantation. J Immunol Res 2018; 2018:2785971. [PMID: 30510964 PMCID: PMC6232810 DOI: 10.1155/2018/2785971] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/10/2018] [Accepted: 09/14/2018] [Indexed: 01/10/2023] Open
Abstract
The multifunctional role of mast cells (MCs) in the immune system is complex and has not fully been explored. MCs reside in tissues and mucous membranes such as the lung, digestive tract, and skin which are strategically located at interfaces with the external environment. These cells, therefore, will encounter external stimuli and pathogens. MCs modulate both the innate and the adaptive immune response in inflammatory disorders including transplantation. MCs can have pro- and anti-inflammatory functions, thereby regulating the outcome of lung transplantation through secretion of mediators that allow interaction with other cell types, particularly innate lymphoid cells (ILC2). ILC2 cells are a unique population of hematopoietic cells that coordinate the innate immune response against a variety of threats including infection, tissue damage, and homeostatic disruption. In addition, MCs can modulate alloreactive T cell responses or assist in T regulatory (Treg) cell activity. This paper outlines the current understanding of the role of MCs in lung transplantation, with a specific focus on their interaction with ILC2 cells within the engrafted organ.
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Forsberg A, Nilsson M, Jakobsson S, Lennerling A, Kisch A. Fear of graft rejection 1-5 years after lung transplantation-A nationwide cohort study. Nurs Open 2018; 5:484-490. [PMID: 30338093 PMCID: PMC6177545 DOI: 10.1002/nop2.184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/21/2018] [Indexed: 11/25/2022] Open
Abstract
AIM To explore the perceived threat of the risk of graft rejection and its relationship to psychological general well-being and self-efficacy 1-5 years after lung transplantation. DESIGN A nationwide, cross-sectional cohort study as a part of the Self-management after thoracic transplantation study. METHODS A total of 117 lung transplant recipients due for their yearly follow-up one (N = 35), two (N = 28), three (N = 23), four (N = 20) and 5 years (N = 11) after lung transplantation were included. We used three instruments; the Perceived Threat of the Risk of Graft Rejection, the Psychological General Well-being and Self-efficacy in chronic illness. RESULTS The lung recipients reported an overall low perceived threat of the risk of graft rejection with no gender differences. Intrusive anxiety explained 24.7% of the variance in the PGWB-sum (p ≤ 0.001) and makes a statistically significant (β = -497; p ≤ 0.001) unique contribution to the overall psychological general well-being (95%CI 3.004-1.515).
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Affiliation(s)
- Anna Forsberg
- Institute of Health SciencesLund UniversityLundSweden
- Department of Thoracic Transplantation and CardiologySkåne University HospitalSkåneSweden
| | - Madeleine Nilsson
- Queen Silvia Children´s Hospital, Sahlgrenska University HospitalGothenburgSweden
| | - Sofie Jakobsson
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Annette Lennerling
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
- The Department of TransplantationSahlgrenska University HospitalGothenburgSweden
| | - Annika Kisch
- The Department of HaematologySkåne University HospitalSkåneSweden
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Li SS, Tumin D, Krone KA, Boyer D, Kirkby SE, Mansour HM, Hayes D. Risks associated with lung transplantation in cystic fibrosis patients. Expert Rev Respir Med 2018; 12:893-904. [PMID: 30198350 DOI: 10.1080/17476348.2018.1522254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Survival after lung transplantation lags behind outcomes of other solid organ transplants, and complications from lung transplant are the second most common cause of death in cystic fibrosis. Evolving surgical techniques, therapeutics, and perioperative management have improved short-term survival after lung transplantation, yet have not translated into significant improvement in long-term mortality. Areas covered: We review risk factors for poor long-term outcomes among patients with cystic fibrosis undergoing lung transplantation to highlight areas for improvement. This includes reasons for organ dysfunction, complications of immunosuppression, further exacerbation of extrapulmonary complications of cystic fibrosis, and quality of life. A literature search was performed using PubMed-indexed journals. Expert commentary: There are multiple medical and socioeconomic barriers that threaten long-term survival following lung transplant for patients with cystic fibrosis. An understanding of the causes of each could elucidate treatment options. There is a lack of prospective, multicenter, randomized control trials due to cost, complexity, and feasibility. Ongoing prospective studies should be reserved for the most promising interventions identified in retrospective studies in order to improve long-term outcomes.
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Affiliation(s)
- Susan S Li
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Dmitry Tumin
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Katie A Krone
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Debra Boyer
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Stephen E Kirkby
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Heidi M Mansour
- c Department of Pharmacology and Toxicology , The University of Arizona Colleges of Pharmacy and Medicine , Tucson , AZ , USA
| | - Don Hayes
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
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Wojarski J, Ochman M, Medrala W, Kulaczkowska Z, Karolak W, Maruszewski M, Urlik M, Wozniak-Grygiel E, Sioła M, Latos M, Biniszkiewicz P, Pyrc K, Zeglen S. Bacterial Infections During Hospital Stay and Their Impact on Mortality After Lung Transplantation: A Single-Center Study. Transplant Proc 2018; 50:2064-2069. [DOI: 10.1016/j.transproceed.2017.11.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/21/2017] [Indexed: 02/02/2023]
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Nichols JE, La Francesca S, Niles JA, Vega SP, Argueta LB, Frank L, Christiani DC, Pyles RB, Himes BE, Zhang R, Li S, Sakamoto J, Rhudy J, Hendricks G, Begarani F, Liu X, Patrikeev I, Pal R, Usheva E, Vargas G, Miller A, Woodson L, Wacher A, Grimaldo M, Weaver D, Mlcak R, Cortiella J. Production and transplantation of bioengineered lung into a large-animal model. Sci Transl Med 2018; 10:10/452/eaao3926. [DOI: 10.1126/scitranslmed.aao3926] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 06/19/2018] [Indexed: 12/26/2022]
Abstract
The inability to produce perfusable microvasculature networks capable of supporting tissue survival and of withstanding physiological pressures without leakage is a fundamental problem facing the field of tissue engineering. Microvasculature is critically important for production of bioengineered lung (BEL), which requires systemic circulation to support tissue survival and coordination of circulatory and respiratory systems to ensure proper gas exchange. To advance our understanding of vascularization after bioengineered organ transplantation, we produced and transplanted BEL without creation of a pulmonary artery anastomosis in a porcine model. A single pneumonectomy, performed 1 month before BEL implantation, provided the source of autologous cells used to bioengineer the organ on an acellular lung scaffold. During 30 days of bioreactor culture, we facilitated systemic vessel development using growth factor–loaded microparticles. We evaluated recipient survival, autograft (BEL) vascular and parenchymal tissue development, graft rejection, and microbiome reestablishment in autografted animals 10 hours, 2 weeks, 1 month, and 2 months after transplant. BEL became well vascularized as early as 2 weeks after transplant, and formation of alveolar tissue was observed in all animals (n = 4). There was no indication of transplant rejection. BEL continued to develop after transplant and did not require addition of exogenous growth factors to drive cell proliferation or lung and vascular tissue development. The sterile BEL was seeded and colonized by the bacterial community of the native lung.
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Affiliation(s)
- Joan E. Nichols
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | | | - Jean A. Niles
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - Stephanie P. Vega
- Department of Microbiology and Immunology, UTMB, Galveston, TX 77555, USA
| | | | - Luba Frank
- Department of Radiology, UTMB, Galveston, TX 77555, USA
| | - David C. Christiani
- Pulmonary Division, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Environmental, Occupational Medicine, Epidemiology Department, TH Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Richard B. Pyles
- Galveston National Laboratory, Assay Development Core, UTMB, Galveston, TX 77555, USA
| | - Blanca E. Himes
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ruyang Zhang
- Environmental, Occupational Medicine, Epidemiology Department, TH Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Su Li
- Environmental, Occupational Medicine, Epidemiology Department, TH Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Jason Sakamoto
- Houston Methodist Hospital Research Institute, Houston, TX 77030, USA
| | - Jessica Rhudy
- Houston Methodist Hospital Research Institute, Houston, TX 77030, USA
| | - Greg Hendricks
- Radiology Division of Cell Biology, University of Massachusetts Medical School, Worchester, MA 01605, USA
| | - Filippo Begarani
- Houston Methodist Hospital Research Institute, Houston, TX 77030, USA
| | - Xuewu Liu
- Houston Methodist Hospital Research Institute, Houston, TX 77030, USA
| | - Igor Patrikeev
- Center for Biomedical Engineering, UTMB, Galveston, TX 77555, USA
| | - Rahul Pal
- Center for Biomedical Engineering, UTMB, Galveston, TX 77555, USA
| | - Emiliya Usheva
- University of Texas Southwestern Medical School, Dallas, TX 75390, USA
| | - Grace Vargas
- Center for Biomedical Engineering, UTMB, Galveston, TX 77555, USA
| | - Aaron Miller
- Galveston National Laboratory, Assay Development Core, UTMB, Galveston, TX 77555, USA
| | - Lee Woodson
- Department of Anesthesiology, UTMB, Galveston, TX 77555, USA
| | - Adam Wacher
- Department of Anesthesiology, UTMB, Galveston, TX 77555, USA
| | - Maria Grimaldo
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - Daniil Weaver
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - Ron Mlcak
- Shriners Hospital for Children, Galveston, TX 77550, USA
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Lo WK, Goldberg HJ, Boukedes S, Burakoff R, Chan WW. Proton Pump Inhibitors Independently Protect Against Early Allograft Injury or Chronic Rejection After Lung Transplantation. Dig Dis Sci 2018; 63:403-410. [PMID: 29094310 DOI: 10.1007/s10620-017-4827-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 10/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acid reflux has been associated with poor outcomes following lung transplantation. Unlike surgical fundoplication, the role of noninvasive, pharmacologic acid suppression remains uncertain. AIMS To assess the relationship between post-transplant acid suppression with proton pump inhibitors (PPI) or histamine-2 receptor antagonists (H2RA) and onset of early allograft injury or chronic rejection following lung transplantation. METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary center in 2007-2014. Patients with pre-transplant antireflux surgery were excluded. Time-to-event analysis using the Cox proportional hazards model was applied to assess acid suppression therapy and onset of acute or chronic rejection, defined histologically and clinically. Subgroup analyses were performed to assess PPI versus H2RA use. RESULTS A total of 188 subjects (60% men, mean age 54, follow-up 554 person-years) met inclusion criteria. During follow-up, 115 subjects (61.5%) developed rejection, with all-cause mortality of 27.6%. On univariate analyses, acid suppression and BMI, but not other patient demographics, were associated with rejection. The Kaplan-Meier curve demonstrated decreased rejection with use of acid suppression therapy (log-rank p = 0.03). On multivariate analyses, acid suppression (HR 0.39, p = 0.04) and lower BMI (HR 0.67, p = 0.04) were independently predicted against rejection. Subgroup analyses demonstrated that persistent PPI use was more protective than H2RA or no antireflux medications. CONCLUSIONS Post-lung transplant exposure to persistent PPI therapy results in the greatest protection against rejection in lung transplant recipients, independent of other clinical predictors including BMI, suggesting that PPI may have antireflux or anti-inflammatory effects in enhancing allograft protection.
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Affiliation(s)
- Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Gastroenterology, Boston VA Healthcare System, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hilary J Goldberg
- Harvard Medical School, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Steve Boukedes
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert Burakoff
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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Blatter JA, Sweet SC, Conrad C, Danziger-Isakov LA, Faro A, Goldfarb SB, Hayes D, Melicoff E, Schecter M, Storch G, Visner GA, Williams NM, Wang D. Anellovirus loads are associated with outcomes in pediatric lung transplantation. Pediatr Transplant 2018; 22:10.1111/petr.13069. [PMID: 29082660 PMCID: PMC5811341 DOI: 10.1111/petr.13069] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2017] [Indexed: 12/17/2022]
Abstract
Anelloviruses are DNA viruses ubiquitously present in human blood. Due to their elevated levels in immunosuppressed patients, anellovirus levels have been proposed as a marker of immune status. We hypothesized that low anellovirus levels, reflecting relative immunocompetence, would be associated with adverse outcomes in pediatric lung transplantation. We assayed blood samples from 57 patients in a multicenter study for alpha- and betatorquevirus, two anellovirus genera. The primary short-term outcome of interest was acute rejection, and longer-term outcomes were analyzed individually and as "composite" (death, chronic rejection, or retransplant within 2 years). Patients with low alphatorquevirus levels at 2 weeks post-transplantation were more likely to develop acute rejection within 3 months after transplant (P = .013). Low betatorquevirus levels at 6 weeks and 6 months after transplant were associated with death (P = .047) and the composite outcome (P = .017), respectively. There was an association between low anellovirus levels and adverse outcomes in pediatric lung transplantation. Alphatorquevirus levels were associated with short-term outcomes (ie, acute rejection), while betatorquevirus levels were associated with longer-term outcomes (ie, death, or composite outcome within 2 years). These observations suggest that anelloviruses may serve as useful biomarkers of immune status and predictors of adverse outcomes.
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Affiliation(s)
- Joshua A. Blatter
- Department of Pediatrics, Washington University School of Medicine, St. Louis MO,Correspondence and reprint requests to: Joshua A. Blatter, MD, MPH, Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8116, Saint Louis, MO 63110, Phone: 314-454-2694, Fax: 314-454-2515,
| | - Stuart C. Sweet
- Department of Pediatrics, Washington University School of Medicine, St. Louis MO
| | - Carol Conrad
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Lara A. Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | | | - Don Hayes
- Department of Pediatrics, The Ohio State University, Columbus, OH
| | | | - Marc Schecter
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Gregory Storch
- Department of Pediatrics, Washington University School of Medicine, St. Louis MO
| | - Gary A. Visner
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - David Wang
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis MO,Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis MO
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50
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Pathology of Lung Rejection: Cellular and Humoral Mediated. LUNG TRANSPLANTATION 2018. [PMCID: PMC7122533 DOI: 10.1007/978-3-319-91184-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Acute rejection is an important risk factor for bronchiolitis obliterans syndrome, the clinical manifestation of chronic airway rejection in lung allograft recipients. Patients with acute rejection might be asymptomatic or present with symptoms that are not specific and can be also seen in other conditions. Clinical tests such as pulmonary function tests and imaging studies among others usually are abnormal; however, their results are also not specific for acute rejection. Histopathologic features of acute rejection in adequate samples of transbronchial lung biopsy of the lung allograft are currently the gold standard to assess for acute rejection in lung transplant recipients. Acute alloreactive injury can affect both the vasculature and the airways. Currently, the guidelines of the 2007 International Society of Heart and Lung Transplantation consensus conference are recommended for the histopathologic assessment of rejection. There are no specific morphologic features recognized to diagnose antibody-mediated rejection (AMR) in lung allografts. Therefore, the diagnosis of AMR currently requires a “triple test” including clinical features, serologic evidence of donor-specific antibodies, and pathologic findings supportive of AMR. Complement 4d deposition is used to support a diagnosis of AMR in many solid organ transplants; however, its significance for the diagnosis of AMR in lung allografts is not entirely clear. This chapter discusses the currently recommended guidelines for the assessment of cellular rejection of lung allografts and summarizes our knowledge about morphologic features and immunophenotypic tests that might help in the diagnosis of AMR.
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