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Belousova N, Cheng A, Matelski J, Vasileva A, Wu JKY, Ghany R, Martinu T, Ryan CM, Chow CW. Effects of donor smoking history on early post-transplant lung function measured by oscillometry. Front Med (Lausanne) 2024; 11:1328395. [PMID: 38654829 PMCID: PMC11037252 DOI: 10.3389/fmed.2024.1328395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/22/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Prior studies assessing outcomes of lung transplants from cigarette-smoking donors found mixed results. Oscillometry, a non-invasive test of respiratory impedance, detects changes in lung function of smokers prior to diagnosis of COPD, and identifies spirometrically silent episodes of rejection post-transplant. We hypothesise that oscillometry could identify abnormalities in recipients of smoking donor lungs and discriminate from non-smoking donors. Methods This prospective single-center cohort study analysed 233 double-lung recipients. Oscillometry was performed alongside routine conventional pulmonary function tests (PFT) post-transplant. Multivariable regression models were constructed to compare oscillometry and conventional PFT parameters between recipients of lungs from smoking vs non-smoking donors. Results The analysis included 109 patients who received lungs from non-smokers and 124 from smokers. Multivariable analysis identified significant differences between recipients of smoking and non-smoking lungs in the oscillometric measurements R5-19, X5, AX, R5z and X5z, but no differences in %predicted FEV1, FEV1/FVC, %predicted TLC or %predicted DLCO. An analysis of the smoking group also demonstrated associations between increasing smoke exposure, quantified in pack years, and all the oscillometry parameters, but not the conventional PFT parameters. Conclusion An interaction was identified between donor-recipient sex match and the effect of smoking. The association between donor smoking and oscillometry outcomes was significant predominantly in the female donor/female recipient group.
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Affiliation(s)
- Natalia Belousova
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pneumology, Aduch Cystic Fibrosis and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Albert Cheng
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Matelski
- Pneumology, Aduch Cystic Fibrosis and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Anastasiia Vasileva
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joyce K. Y. Wu
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clodagh M. Ryan
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Tonronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Saddoughi SA, Martinu T, Patriquin C, Barth D, Huszti E, Ghany R, Tinckam K, McRae K, Singer LG, Keshavjee S, Cypel M, Aversa M. Impact of intraoperative therapeutic plasma exchange on bleeding in lung transplantation. J Heart Lung Transplant 2024; 43:414-419. [PMID: 37813131 DOI: 10.1016/j.healun.2023.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/21/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Our program uses a desensitization protocol that includes intraoperative therapeutic plasma exchange (iTPE) for crossmatch-positive lung transplants, which improves access to lung transplant for sensitized candidates while mitigating immunologic risk. Although we have reported excellent outcomes for sensitized patients with the use of this protocol, concern for perioperative bleeding appears to have hindered broader adoption of it at other programs. We conducted a retrospective cohort study to quantify the impact of iTPE on perioperative bleeding in lung transplantation. METHODS All first-time lung transplant recipients from 2014 to 2019 who received iTPE were compared to those who did not. Multivariable logistic regression was used to determine the association between iTPE and large-volume perioperative transfusion requirements (≥5 packed red blood cell units within 24 hours of transplant start), adjusted for disease type, transplant type, and extracorporeal membrane oxygenation or cardiopulmonary bypass use. The incidence of hemothorax (requiring reoperation within 7 days of lung transplant) and 30-day posttransplant mortality were compared between the 2 groups using chi-square test. RESULTS One hundred forty-two patients (16%) received iTPE, and 755 patients (84%) did not. The mean number of perioperative pRBC transfusions was 4.2 among patients who received iTPE and 2.9 among patients who did not. iTPE was associated with increased odds of requiring large-volume perioperative transfusion (odds ratio 1.9; 95% confidence interval: 1.2-2.9, p-value = 0.007) but was not associated with an increased incidence of hemothorax (5% in both groups, p = 0.99) or 30-day posttransplant mortality (3.5% among patients who received iTPE vs 2.1% among patients who did not, p = 0.31). CONCLUSIONS This study demonstrates that the use of iTPE in lung transplantation may increase perioperative bleeding but not to a degree that impacts important posttransplant outcomes.
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Affiliation(s)
- Sahar A Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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Kawashima M, Ma J, Huszti E, Levy L, Berra G, Renaud-Picard B, Takahagi A, Ghany R, Sato M, Keshavjee S, Singer L, Husain S, Kumar D, Tikkanen J, Martinu T. Association between cytomegalovirus viremia and long-term outcomes in lung transplant recipients. Am J Transplant 2024:S1600-6135(24)00095-9. [PMID: 38307417 DOI: 10.1016/j.ajt.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/04/2024]
Abstract
Although cytomegalovirus (CMV) viremia/DNAemia has been associated with reduced survival after lung transplantation, its association with chronic lung allograft dysfunction (CLAD) and its phenotypes is unclear. We hypothesized that, in a modern era of CMV prophylaxis, CMV DNAemia would still remain associated with death, but also represent a risk factor for CLAD and specifically restrictive allograft syndrome (RAS)/mixed phenotype. This was a single-center retrospective cohort study of all consecutive adult, first, bilateral-/single-lung transplants done between 2010-2016, consisting of 668 patients. Risks for death/retransplantation, CLAD, or RAS/mixed, were assessed by adjusted cause-specific Cox proportional-hazards models. CMV viral load (VL) was primarily modeled as a categorical variable: undetectable, detectable to 999, 1000 to 9999, and ≥10 000 IU/mL. In multivariable models, CMV VL was significantly associated with death/retransplantation (≥10 000 IU/mL: HR = 2.65 [1.78-3.94]; P < .01), but was not associated with CLAD, whereas CMV serostatus mismatch was (D+R-: HR = 2.04 [1.30-3.21]; P < .01). CMV VL was not associated with RAS/mixed in univariable analysis. Secondary analyses with a 7-level categorical or 4-level ordinal CMV VL confirmed similar results. In conclusion, CMV DNAemia is a significant risk factor for death/retransplantation, but not for CLAD or RAS/mixed. CMV serostatus mismatch may have an impact on CLAD through a pathway independent of DNAemia.
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Affiliation(s)
- Mitsuaki Kawashima
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory Berra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Benjamin Renaud-Picard
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Akihiro Takahagi
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Lianne Singer
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Transplant Infectious Diseases & Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Deepali Kumar
- Transplant Infectious Diseases & Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Ramendra R, Duong A, Zhang CYK, Huszti E, Zhou X, Havlin J, Ghany R, Cypel M, Yeung JC, Keshavjee S, Sage AT, Martinu T. Airway pepsinogen A4 identifies lung transplant recipients with microaspiration and predicts chronic lung allograft dysfunction. J Heart Lung Transplant 2024:S1053-2498(24)00003-2. [PMID: 38211836 DOI: 10.1016/j.healun.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/04/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant. METHODS Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs. RESULTS PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4. CONCLUSIONS Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Allen Duong
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Xuanzi Zhou
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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5
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Belousova N, Huszti E, Li Q, Vasileva A, Ghany R, Gabarin R, El Sanharawi M, Picard C, Hwang D, Levy L, Keshavjee S, Chow CW, Roux A, Martinu T. Center variability in the prognostic value of a cumulative acute cellular rejection "A-score" for long-term lung transplant outcomes. Am J Transplant 2024; 24:89-103. [PMID: 37625646 DOI: 10.1016/j.ajt.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023]
Abstract
The acute rejection score (A-score) in lung transplant recipients, calculated as the average of acute cellular rejection A-grades across transbronchial biopsies, summarizes the cumulative burden of rejection over time. We assessed the association between A-score and transplant outcomes in 2 geographically distinct cohorts. The primary cohort included 772 double lung transplant recipients. The analysis was repeated in 300 patients from an independent comparison cohort. Time-dependent multivariable Cox models were constructed to evaluate the association between A-score and chronic lung allograft dysfunction or graft failure. Landmark analyses were performed with A-score calculated at 6 and 12 months posttransplant. In the primary cohort, no association was found between A-score and graft outcome. However, in the comparison cohort, time-dependent A-score was associated with chronic lung allograft dysfunction both as a time-dependent variable (hazard ratio, 1.51; P < .01) and when calculated at 6 months posttransplant (hazard ratio, 1.355; P = .031). The A-score can be a useful predictor of lung transplant outcomes in some settings but is not generalizable across all centers; its utility as a prognostication tool is therefore limited.
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Affiliation(s)
- Natalia Belousova
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada; Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Anastasiia Vasileva
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada
| | - Ramy Gabarin
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | | | - Clement Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - David Hwang
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada
| | - Liran Levy
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France; Paris Transplant Group, Paris, France
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
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Aversa M, Kiernan J, Martinu T, Patriquin C, Barth D, Li Q, Huszti E, Ghany R, Cypel M, Keshavjee S, Singer LG, Tinckam K. Outcomes after flow cytometry crossmatch-positive lung transplants managed with perioperative desensitization. Am J Transplant 2023; 23:1733-1739. [PMID: 37172694 DOI: 10.1016/j.ajt.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/06/2023] [Accepted: 04/03/2023] [Indexed: 05/15/2023]
Abstract
Our program previously reported successful outcomes following virtual crossmatch (VXM)-positive lung transplants managed with perioperative desensitization, but our ability to stratify their immunologic risk was limited without flow cytometry crossmatch (FCXM) data before 2014. The aim of this study was to determine allograft and chronic lung allograft dysfunction (CLAD)-free survival following VXM-positive/FCXM-positive lung transplants, which are performed at a minority of programs due to the high immunologic risk and lack of data on outcomes. All first-time lung transplant recipients between January 2014 and December 2019 were divided into 3 cohorts: VXM-negative (n = 764), VXM-positive/FCXM-negative (n = 64), and VXM-positive/FCXM-positive (n = 74). Allograft and CLAD-free survival were compared using Kaplan-Meier and multivariable Cox proportional hazards models. Five-year allograft survival was 53% in the VXM-negative cohort, 64% in the VXM-positive/FCXM-negative cohort, and 57% in the VXM-positive/FCXM-positive cohort (P = .7171). Five-year CLAD-free survival was 53% in the VXM-negative cohort, 60% in the VXM-positive/FCXM-negative cohort, and 63% in the VXM-positive/FCXM-positive cohort (P = .8509). This study confirms that allograft and CLAD-free survival of patients who undergo VXM-positive/FCXM-positive lung transplants with the use of our protocol does not differ from those of other lung transplant recipients. Our protocol for VXM-positive lung transplants improves access to transplant for sensitized candidates and mitigates even high immunologic risk.
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Affiliation(s)
- Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Kiernan
- HLA Laboratory, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- HLA Laboratory, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada.
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Ramendra R, Fernández-Castillo JC, Huszti E, Ghany R, Aversa M, Havlin J, Riddell P, Chaparro CM, Singer LG, Liu L, Keshavjee S, Yeung JC, Martinu T. Oesophageal stasis is a risk factor for chronic lung allograft dysfunction and allograft failure in lung transplant recipients. ERJ Open Res 2023; 9:00222-2023. [PMID: 37817870 PMCID: PMC10561084 DOI: 10.1183/23120541.00222-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/04/2023] [Indexed: 10/12/2023] Open
Abstract
Background Morbidity and mortality in lung transplant recipients are often triggered by recurrent aspiration events, potentiated by oesophageal and gastric disorders. Previous small studies have shown conflicting associations between oesophageal function and the development of chronic lung allograft dysfunction (CLAD). Herein, we sought to investigate the relationship between oesophageal motility disorders and long-term outcomes in a large retrospective cohort of lung transplant recipients. Methods All lung transplant recipients at the Toronto Lung Transplant Program from 2012 to 2018 with available oesophageal manometry testing within the first 7 months post-transplant were included in this study. Patients were categorised according to the Chicago Classification of oesophageal disorders (v3.0). Associations between oesophageal motility disorders with the development of CLAD and allograft failure (defined as death or re-transplantation) were assessed. Results Of 487 patients, 57 (12%) had oesophagogastric junction outflow obstruction (OGJOO) and 47 (10%) had a disorder of peristalsis (eight major, 39 minor). In a multivariable analysis, OGJOO was associated with an increased risk of CLAD (HR 1.71, 95% CI 1.15-2.55, p=0.008) and allograft failure (HR 1.69, 95% CI 1.13-2.53, p=0.01). Major disorders of peristalsis were associated with an increased risk of CLAD (HR 1.55, 95% CI 1.01-2.37, p=0.04) and allograft failure (HR 3.33, 95% CI 1.53-7.25, p=0.002). Minor disorders of peristalsis were not significantly associated with CLAD or allograft failure. Conclusion Lung transplant recipients with oesophageal stasis characterised by OGJOO or major disorders of peristalsis were at an increased risk of adverse long-term outcomes. These findings will help with risk stratification of lung transplant recipients and personalisation of treatment for aspiration prevention.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Juan C. Fernández-Castillo
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Peter Riddell
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Cecilia M. Chaparro
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Lianne G. Singer
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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8
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Levy L, Moshkelgosha S, Huszti E, Hunter S, Renaud-Picard B, Berra G, Kawashima M, Fernandez-Castillo J, Fuchs E, Dianti M, Ghany R, Keshavjee S, Singer LG, Tikkanen J, Martinu T. Pulmonary epithelial markers in phenotypes of chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:1152-1160. [PMID: 36963446 DOI: 10.1016/j.healun.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Airway epithelial injury is thought to be a key event in the pathogenesis of chronic lung allograft dysfunction (CLAD). We investigated whether markers of epithelial activity and injury in bronchoalveolar lavage fluid (BAL) correlate with CLAD diagnosis and major CLAD phenotypes: bronchiolitis obliterans syndrome (BOS) vs restrictive allograft syndrome (RAS)-related phenotypes (including RAS, mixed phenotype, and all other patients with RAS-like opacities). METHODS CLAD status and phenotypes were retrospectively determined in a cohort of all consecutive adult, first, bilateral lung transplants performed 2010-2015, with available BAL samples. All patients with RAS-related phenotypes were included and 1:1 matched with BOS patients based on the time from transplant to CLAD-onset. Subjects who were CLAD-free for a minimum of 3 years post-transplant were 1:1 matched to CLAD patients and included as controls. Proteins that maintain the barrier function of the airway epithelial mucosa (club cell secretory protein, surfactant protein-D and epithelial mucins: MUC1, MUC5AC, MUC5B, MUC16), as well as epithelial cell death markers (M30&M65 representing epithelial cell apoptosis and overall death, respectively), were measured in BAL obtained within 6-months post CLAD onset using a double-sandwich ELISA or a multiplex bead assay. Protein levels were compared using Mann-Whitney-U-test. Association between protein levels and graft survival was assessed using Cox proportional hazards models, adjusted for CMV serology mismatch status and CLAD phenotype. RESULTS Fifty-four CLAD (27 BOS, 11 RAS, 7 mixed, 9 others with RAS-like opacities) patients and 23 CLAD-free controls were included. Median BAL levels were significantly higher in patients with CLAD compared to CLAD-free controls for M30 (124.5 vs 88.7 U/L), MUC1 (6.8 vs 3.2 pg/mL), and MUC16 (121.0 vs 30.1 pg/mL). When comparing CLAD phenotypes, M30 was significantly higher in patients with RAS-related phenotypes than BOS (160.9 vs 114.6 U/L). In multivariable models, higher M30 and MUC5B levels were associated with decreased allograft survival after CLAD onset independent of phenotype (p < 0.05 for all). CONCLUSIONS Airway epithelial mucins and cell death markers are enhanced in the BAL of patients with CLAD and can assist in differentiating between CLAD phenotypes and post-CLAD outcomes. Abnormal airway mucin expression and epithelial cell death may be involved in the pathogenesis of CLAD, and therefore their detection may aid in future selection of targeted therapies.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Sarah Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Gregory Berra
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mitsuaki Kawashima
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Eyal Fuchs
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Milagros Dianti
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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9
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Vasileva A, Hanafi N, Huszti E, Matelski J, Belousova N, Wu JKY, Martinu T, Ghany R, Keshavjee S, Tikkanen J, Cypel M, Yeung JC, Ryan CM, Chow CW. Intra-subject variability in oscillometry correlates with acute rejection and CLAD post-lung transplant. Front Med (Lausanne) 2023; 10:1158870. [PMID: 37305133 PMCID: PMC10248398 DOI: 10.3389/fmed.2023.1158870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
Background Chronic lung allograft dysfunction (CLAD) is the major cause of death post-lung transplantation, with acute cellular rejection (ACR) being the biggest contributing risk factor. Although patients are routinely monitored with spirometry, FEV1 is stable or improving in most ACR episodes. In contrast, oscillometry is highly sensitive to respiratory mechanics and shown to track graft injury associated with ACR and its improvement following treatment. We hypothesize that intra-subject variability in oscillometry measurements correlates with ACR and risk of CLAD. Methods Of 289 bilateral lung recipients enrolled for oscillometry prior to laboratory-based spirometry between December 2017 and March 2020, 230 had ≥ 3 months and 175 had ≥ 6 months of follow-up. While 37 patients developed CLAD, only 29 had oscillometry at time of CLAD onset and were included for analysis. These 29 CLAD patients were time-matched with 129 CLAD-free recipients. We performed multivariable regression to investigate the associations between variance in spirometry/oscillometry and the A-score, a cumulative index of ACR, as our predictor of primary interest. Conditional logistic regression models were built to investigate associations with CLAD. Results Multivariable regression showed that the A-score was positively associated with the variance in oscillometry measurements. Conditional logistic regression models revealed that higher variance in the oscillometry metrics of ventilatory inhomogeneity, X5, AX, and R5-19, was independently associated with increased risk of CLAD (p < 0.05); no association was found for variance in %predicted FEV1. Conclusion Oscillometry tracks graft injury and recovery post-transplant. Monitoring with oscillometry could facilitate earlier identification of graft injury, prompting investigation to identify treatable causes and decrease the risk of CLAD.
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Affiliation(s)
- Anastasiia Vasileva
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nour Hanafi
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Natalia Belousova
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Joyce K. Y. Wu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clodagh M. Ryan
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
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10
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Zuñiga AV, Kiernan J, Martinu T, Singer L, Ghany R, Yeung J, Cypel M, Keshavjee S, Tinckam K, Aversa M. Risk Stratifying by DQA and Risk Epitope Mismatches in Lung Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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11
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Saddoughi S, Martinu T, Singer L, Ge X, Ghany R, Huszti E, Patriquin C, Barth D, McRae K, Keshavjee S, Cypel M, Aversa M. Impact of Intraoperative Therapeutic Plasma Exchange on Bleeding in Lung Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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12
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Dianti M, Martinu T, Sidhu A, Huszti E, Ghany R, Singer L, Aversa M. Diagnostic Utility of Surveillance Transbronchial Biopsies after the First Post-Lung Transplant Year. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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13
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Riddell P, Ma J, Lazarte J, Birriel D, Ulahannan A, Ghany R, Delgado D, Rao V, Keshavjee S, Martinu T, Tikkanen J, Juvet SC. Donor and recipient human leukocyte antigen-G polymorphisms modulate the risk of adverse immunologic events following lung transplantation. Am J Transplant 2023; 23:393-400. [PMID: 36695689 DOI: 10.1016/j.ajt.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/21/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023]
Abstract
The long-term benefits of lung transplantation (LTx) are limited by pathogenic alloimmune responses that drive injury, inflammation, and chronic dysfunction. Human leukocyte antigen-G (HLA-G) plays a key role in the modulation of these pathways. This study assesses the impact of the HLA-G genotype on immunologic risk and survival following LTx. This retrospective cohort study included 289 bilateral LTx. Recipient and donor HLA-G genotypes were analyzed to identify associations with de novo donor-specific antibodies, acute rejection, chronic lung allograft dysfunction, and allograft survival. We further assessed these associations, both individually and in paired analysis, based on a grouped haplotype classification of HLA-G expression. Donor HLA-G single nucleotide polymorphisms were associated with allograft injury, the onset of chronic lung allograft dysfunction following injury, and allograft survival. Recipient HLA-G single nucleotide polymorphisms were associated with allograft injury, cellular rejection, and donor-specific antibody formation. "Low HLA-G expression" donor haplotypes were associated with impaired allograft survival, as were "low HLA-G expression" donor-recipient haplotype pairs. This study provides compelling evidence for the role of HLA-G in modulating immunologic risk after LTx. Our results highlight the importance of both donor and recipient HLA-G genotypes on the overall risk profile and underscore the lasting influence of donor genotype on lung transplant outcomes.
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Affiliation(s)
- Peter Riddell
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, Canada
| | - Julieta Lazarte
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Daniella Birriel
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Ambily Ulahannan
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Diego Delgado
- Heart Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Vivek Rao
- Heart Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Stephen C Juvet
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.
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14
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Zhang CYK, Ahmed M, Huszti E, Levy L, Hunter SE, Boonstra KM, Moshkelgosha S, Sage AT, Azad S, Ghany R, Yeung JC, Crespin OM, Singer LG, Keshavjee S, Martinu T. Utility of bile acids in large airway bronchial wash versus bronchoalveolar lavage as biomarkers of microaspiration in lung transplant recipients: a retrospective cohort study. Respir Res 2022; 23:219. [PMID: 36028826 PMCID: PMC9419323 DOI: 10.1186/s12931-022-02131-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background Bronchoalveolar lavage (BAL) is a key tool in respiratory medicine for sampling the distal airways. BAL bile acids are putative biomarkers of pulmonary microaspiration, which is associated with poor outcomes after lung transplantation. Compared to BAL, large airway bronchial wash (LABW) samples the tracheobronchial space where bile acids may be measurable at more clinically relevant levels. We assessed whether LABW bile acids, compared to BAL bile acids, are more strongly associated with poor clinical outcomes in lung transplant recipients. Methods Concurrently obtained BAL and LABW at 3 months post-transplant from a retrospective cohort of 61 lung transplant recipients were analyzed for taurocholic acid (TCA), glycocholic acid (GCA), and cholic acid by mass spectrometry and 10 inflammatory proteins by multiplex immunoassay. Associations between bile acids with inflammatory proteins and acute lung allograft dysfunction were assessed using Spearman correlation and logistic regression, respectively. Time to chronic lung allograft dysfunction and death were evaluated using multivariable Cox proportional hazards and Kaplan–Meier methods. Results Most bile acids and inflammatory proteins were higher in LABW than in BAL. LABW bile acids correlated with inflammatory proteins within and between sample type. LABW TCA and GCA were associated with acute lung allograft dysfunction (OR = 1.368; 95%CI = 1.036–1.806; P = 0.027, OR = 1.064; 95%CI = 1.009–1.122; P = 0.022, respectively). No bile acids were associated with chronic lung allograft dysfunction. Adjusted for risk factors, LABW TCA and GCA predicted death (HR = 1.513; 95%CI = 1.014–2.256; P = 0.042, HR = 1.597; 95%CI = 1.078–2.366; P = 0.020, respectively). Patients with LABW TCA in the highest tertile had worse survival compared to all others. Conclusions LABW bile acids are more strongly associated than BAL bile acids with inflammation, acute lung allograft dysfunction, and death in lung transplant recipients. Collection of LABW may be useful in the evaluation of microaspiration in lung transplantation and other respiratory diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02131-5.
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Affiliation(s)
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Sarah E Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Kristen M Boonstra
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Sassan Azad
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Oscar M Crespin
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada. .,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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15
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Zhang C, Ramendra R, Fernandez-Castillo J, Berra G, Ghany R, Tikkanen J, Singer L, Aversa M, Huszti E, Keshavjee S, Yeung J, Martinu T. Association of Chronic Proton Pump Inhibitor Use in Lung Transplant Recipients with Long-Term Outcomes: A Retrospective Cohort Study. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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Fernandez-Castillo J, Ramendra R, Huszti E, Zhang K, Ghany R, Chaparro C, Singer L, Keshavjee S, Aversa M, Yeung J, Martinu T. Lower-than-Standard Cutoff Number of Reflux Episodes is Associated with Worse Lung Transplant Outcomes. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Belousova N, Gabarin R, Vasileva A, Levy L, Ghany R, Huszti E, Roux A, Chow C, Martinu T. The Normalised Acute Rejection Score in the First Year Post Transplant and Its Association with CLAD. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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18
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Choe E, Ulahannah A, Ghany R, Kiernan J, Patriquin C, Barth D, Cypel M, Keshavjee S, Singer L, Tinckam K, Juvet S, Martinu T, Aversa M. The Role of Anti-Thymocyte Globulin in Peri-Operative Desensitization for Donor Specific Antibody Positive Lung Transplants. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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19
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Ramendra R, Fernández-Castillo J, Huszti E, Ghany R, Aversa M, Riddell P, Chaparro C, Singer L, Keshavjee S, Yeung J, Martinu T. Esophageal Disorders in Lung Transplant Recipients: Association with Chronic Lung Allograft Dysfunction and Survival. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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20
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Berra G, Allen J, Duong A, Levy L, Kawashima M, Renaud-Picard B, Ghany R, McInnis M, Keshavjee S, Yeung J, Juvet S, Martinu T. Transcriptional Landscape of Chronic Lung Allograft Rejection in Humans. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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21
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Fuchs E, Levy L, Huszti E, Renaud-Picard B, Berra G, Kawashima M, Takahagi A, Ghany R, Havlin J, McInnis MC, Keshavjee S, Singer LG, Tikkanen J, Chow CW, Martinu T. Significance of phenotype change after chronic lung allograft dysfunction onset. Transpl Int 2021; 34:2620-2632. [PMID: 34748217 DOI: 10.1111/tri.14157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 01/26/2023]
Abstract
Definitions for chronic lung allograft dysfunction (CLAD) phenotypes were recently revised (2019 ISHLT consensus). Post-CLAD onset phenotype transition may occur as a result of change in obstruction, restriction, or RAS-like opacities (RLO). We aimed to assess the prevalence and prognostic implications of these transitions. This was a single-center, retrospective cohort study of bilateral lung transplants performed in 2009-2015. CLAD phenotypes were determined per ISHLT guidelines. CLAD phenotype transition was defined as a sustained change in obstruction, restriction or RLO. We specifically focused on phenotype changes based on RLO emergence. Association of RLO development with time to death or retransplant were assessed using Kaplan-Meier and Cox proportional hazards models. Among 211 patients with CLAD, 47 (22.2%) experienced a phenotype transition. Nineteen patients developed RLO. Development of RLO phenotype after CLAD onset was associated with a shorter time to death/retransplant when considering the entire CLAD patient cohort (HR = 4.00, CI 2.74-5.83, P < 0.001) and also when restricting the analysis to only patients with a Non-RLO phenotype at CLAD onset (HR 9.64, CI 5.52-16.84, P < 0.0001). CLAD phenotype change based on emergence of RAS-like opacities implies a worse outcome. This highlights the clinical importance of imaging follow-up to monitor for phenotype transitions after CLAD onset.
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Affiliation(s)
- Eyal Fuchs
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Institute of Pulmonary Medicine, Sackler Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Gregory Berra
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Mitsuaki Kawashima
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Akihiro Takahagi
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Micheal C McInnis
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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22
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Di Nardo M, Del Sorbo L, Sage A, Ma J, Liu M, Yeung JC, Valero J, Ghany R, Cypel M, Keshavjee S. Predicting donor lung acceptance for transplant during ex vivo lung perfusion: The EX vivo lung PerfusIon pREdiction (EXPIRE). Am J Transplant 2021; 21:3704-3713. [PMID: 33872459 DOI: 10.1111/ajt.16616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 01/25/2023]
Abstract
Ex vivo lung perfusion (EVLP) has being increasingly used for the pretransplant assessment of extended-criteria donor lungs. Mathematical models to predict lung acceptance during EVLP have not been reported so far. Thus, we hypothesized that predictors of lung acceptance could be identified and used to develop a mathematical model describing the clinical decision-making process used in our institution. Donor lungs characteristics and EVLP physiologic parameters included in our EVLP registry were examined (derivation cohort). Multivariable logistic regression analysis was performed to identify predictors independently associated with lung acceptance. A mathematical model (EX vivo lung PerfusIon pREdiction [EXPIRE] model) for each hour of EVLP was developed and validated using a new cohort (validation cohort). Two hundred eighty donor lungs were assessed with EVLP. Of these, 186 (66%) were accepted for transplantation. ΔPO2 and static compliance/total lung capacity were identified as independent predictors of lung acceptance and their respective cut-off values were determined. The EXPIRE model showed a low discriminative power at the first hour of EVLP assessment (AUC: 0.69 [95% CI: 0.62-0.77]), which progressively improved up to the fourth hour (AUC: 0.87 [95% CI: 0.83-0.92]). In a validation cohort, the EXPIRE model demonstrated good discriminative power, peaking at the fourth hour (AUC: 0.85 [95% CI: 0.76-0.94]). The EXPIRE model may help to standardize lung assessment in centers using the Toronto EVLP technique and improve overall transplant rates.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy.,Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Medical and Surgical Intensive Care Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Andrew Sage
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jonathan C Yeung
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jerome Valero
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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23
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Aversa M, Martinu T, Patriquin C, Cypel M, Barth D, Ghany R, Ma J, Keshavjee S, Singer LG, Tinckam K. Long-term outcomes of sensitized lung transplant recipients after peri-operative desensitization. Am J Transplant 2021; 21:3444-3448. [PMID: 34058795 DOI: 10.1111/ajt.16707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/07/2021] [Accepted: 05/22/2021] [Indexed: 01/25/2023]
Abstract
The Toronto Lung Transplant Program has been using a peri-operative desensitization regimen of plasma exchange, intravenous immune globulin, and antithymocyte globulin in order to accept donor-specific antibody (DSA)-positive lung transplants safely since 2008. There are no long-term data on the impact of this practice on allograft survival or the development of chronic lung allograft dysfunction (CLAD). We extended our prior study to include long-term follow-up of 340 patients who received lung transplants between January 1, 2008 and December 31, 2011. We compared allograft survival and CLAD-free survival among patients in three cohorts: DSA-positive, panel reactive antibody (PRA)-positive/DSA-negative, and unsensitized at the time of transplant. The median follow-up time in this extension study was 6.7 years. Among DSA-positive, PRA-positive/DSA-negative, and unsensitized patients, the median allograft survival was 8.4, 7.9, and 5.8 years, respectively (p = .5908), and the median CLAD-free survival was 6.8, 7.3, and 5.7 years, respectively (p = .5448). This follow-up study confirms that long-term allograft survival and CLAD-free survival of patients who undergo DSA-positive lung transplants with the use of our protocol do not differ from other lung transplant recipients. Use of protocols such as ours, therefore, may improve access to transplant for sensitized candidates.
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Affiliation(s)
- Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Christopher Patriquin
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - David Barth
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Kathryn Tinckam
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
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24
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Levy L, Huszti E, Berra G, Renaud-Picard B, Kawashima M, Takahagi A, Moshkelgosha S, Ghany R, Fuchs E, Chow CW, Keshavjee S, Singer LG, Tikkanen J, Martinu T. The accuracy of forced vital capacity for diagnosing restrictive allograft syndrome and mixed phenotype of chronic lung allograft dysfunction. Eur Respir J 2021; 58:13993003.03387-2020. [PMID: 34172465 DOI: 10.1183/13993003.03387-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 02/28/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gregory Berra
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Benjamin Renaud-Picard
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mitsuaki Kawashima
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Akihiro Takahagi
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eyal Fuchs
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,These authors have contributed equally to this work
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.,These authors have contributed equally to this work
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25
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Darley DR, Ma J, Huszti E, Ghany R, Hutcheon M, Chow CW, Tikkanen J, Keshavjee S, Singer LG, Martinu T. Diffusing Capacity for Carbon Monoxide (DLCO): Association with long-term outcomes after Lung Transplantation in a 20-year longitudinal study. Eur Respir J 2021; 59:13993003.03639-2020. [PMID: 34172463 DOI: 10.1183/13993003.03639-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 06/03/2021] [Indexed: 11/05/2022]
Abstract
RATIONALE The diffusing capacity for carbon monoxide corrected for haemoglobin (DLCOcor), measures gas movement across the alveolar-capillary interface. We hypothesised that DLCOcor is a sensitive measure of injurious allograft processes disrupting this interface. OBJECTIVES To determine the prognostic significance of the DLCOcor trajectory on chronic lung allograft dysfunction (CLAD) and survival. METHODS A retrospective analysis was conducted of all bilateral lung transplant recipients at a single centre, between Jan-1998 and Jan-2018, with ≥1 DLCOcor measurements. Low baseline DLCOcor was defined as the failure to achieve a DLCOcor >75% predicted. Drops in DLCOcor were defined as >15% below recent baseline. RESULTS 1259/1492 lung transplant recipients were included. The median time to peak DLCOcor was 354 (range 181-737) days and the mean %-predicted DLCOcor was 80.2% (sd 21.2). Multivariable analysis demonstrated that low baseline DLCOcor was significantly associated with death (HR 1.68, 95% CI 1.27-2.20, p<0.001). Low baseline DLCOcor was not independently associated with CLAD after adjustment for low baseline FEV1 or FVC. Any DLCOcor declines ≥15% were significantly associated with death, independent of concurrent spirometric decline. Lower %-predicted DLCOcor values at CLAD onset were associated with shorter post-CLAD survival (HR 0.75 per 10%-unit change, p<0.01). CONCLUSION Low baseline DLCOcor and post-transplant declines in DLCOcor were significantly associated with survival, independent of spirometric measurements. We propose that DLCOcor testing may allow identification of a sub-phenotype of baseline and chronic allograft dysfunction not captured by spirometry. There may be benefit in routine monitoring of DLCOcor after lung transplantation to identify patients at risk of poor outcomes.
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Affiliation(s)
- David Ross Darley
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Michael Hutcheon
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Lianne Gail Singer
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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26
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Levy L, Huszti E, Ahmed M, Ghany R, Hunter S, Moshkelgosha S, Zhang CYK, Boonstra K, Klement W, Tikkanen J, Singer LG, Keshavjee S, Juvet S, Martinu T. Bronchoalveolar lavage cytokine-based risk stratification of minimal acute rejection in clinically stable lung transplant recipients. J Heart Lung Transplant 2021; 40:1540-1549. [PMID: 34215500 DOI: 10.1016/j.healun.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) remains the most significant risk factor for chronic lung allograft dysfunction (CLAD). While clinically significant or higher-grade (≥A2) ACR is generally treated with augmented immunosuppression (IS), the management of clinically stable grade A1 ACR remains controversial. At our center, patients with clinically stable grade A1 ACR are routinely not treated with augmented IS. While the overall outcomes in this group of patients at our center are equivalent to patients with stable A0 pathology, CLAD and death rates remain overall high. We hypothesized that a distinct cytokine signature at the time of early minimal rejection state would be associated with worse outcomes. Specifically, we aimed to determine whether bronchoalveolar lavage (BAL) biomarkers at the time of first clinically stable grade A1 ACR (CSA1R) are predictive of subsequent CLAD or death. METHODS Among all adult, bilateral, first lung transplants, performed 2010-2016, transbronchial biopsies obtained within the first-year post-transplant were categorized as clinically stable or unstable based on the presence or absence of ≥10% concurrent drop in forced expiratory volume in 1 second (FEV1). We assessed BAL samples obtained at the time of CSA1R episodes, which were not preceded by another ACR (i.e., first episodes). Twenty-one proteins previously associated with ACR or CLAD were measured in the BAL using a multiplex bead assay. Association between protein levels and subsequent CLAD or death was assessed using Cox Proportional Hazards models, adjusted for relevant peri-transplant clinical covariates. RESULTS We identified 75 patients with first CSA1R occurring at a median time of 98 days (range 48.5-197) post-transplant. Median time from transplant to CLAD or death was 1247 (756.5-1921.5) and 1641 days (1024.5-2326.5), respectively. In multivariable models, levels of MCP1/CCL2, S100A8, IL10, TNF-receptor 1, and pentraxin 3 (PTX3) were associated with both CLAD development and death (p < 0.05 for all). PTX3 remained significantly associated with both CLAD and death after adjusting for multiple comparisons. CONCLUSION Our data indicate that a focused BAL protein signature, with PTX3 having the strongest association, may be useful in determining a subset of CSA1R patients at increased risk and may benefit from a more aggressive management strategy.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada; Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Hunter
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kristen Boonstra
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - William Klement
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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27
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Levy L, Moshkelgosha S, Huszti E, Hunter S, Ahmed M, Zhang K, Ghany R, Keshavjee S, Singer L, Tikkanen J, Juvet S, Martinu T. Bronchoalveolar Lavage Markers of Inflammation Early Post Lung-Transplant are Associated with CLAD and Death. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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28
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Zhang C, Ahmed M, Huszti E, Levy L, Hunter S, Boonstra K, Sage A, Ghany R, Liu M, Yeung J, Crespin O, Singer L, Keshavjee S, Martinu T. The Diagnostic and Prognostic Value of Bronchial Wash for Evaluating Microaspiration in Lung Transplant Recipients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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29
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Berra G, Huszti E, Levy L, Kawashima M, Fuchs E, Renaud-Picard B, Riddell P, Dias O, Rajagopala S, Ulahannan A, Ghany R, Singer L, Tikkanen J, Martinu T. Phenotyping CLAD after Single Lung Transplant: Limits and Prognostic Assessment of the 2019 ISHLT Classification System. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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30
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Levy L, Ahmed M, Huszti E, Zhang C, Hunter S, Boonstra K, Sage A, Ghany R, Budev M, Shah P, Reynolds J, Snyder L, Belperio J, Singer L, Palmer S, Keshavjee S, Todd J, Weigt S, Martinu T. Bronchoalveolar Bile Acids are Associated with Acute Rejection, Inflammation, and Allograft Survival: A Multi-Center Study. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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31
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Levy L, Huszti E, Tikkanen J, Fernandez-Castillo J, Ghany R, Keshavjee S, Singer L, Husain S, Martinu T. Clinical Significance of Commensal Bacteria Isolated from Bronchoalveolar Lavage of Lung Transplant Recipients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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32
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Vasileva A, Hanafi N, Matelski J, Wu J, deHaas E, Huang Q, Nadj R, Cheung A, Martinu T, Ghany R, Keshavjee S, Cypel M, Tikkanen J, Ryan C, Chow C. Intra-Subject Variance of Respiratory Oscillometry Reflects Graft Injury and is Associated with Acute Rejection and Chronic Lung Allograft Dysfunction (CLAD) Post Lung Transplant (LTx). J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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33
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Fernandez-Castillo J, Huszti E, Levy L, Ghany R, Riddell P, Chaparro C, Keshavjee S, Singer L, Yeung J, Martinu T. Association between Esophageal Dysmotility and Long-Term Outcomes in Lung Transplant Recipients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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34
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Levy L, Huszti E, Renaud-Picard B, Berra G, Kawashima M, Takahagi A, Fuchs E, Ghany R, Moshkelgosha S, Keshavjee S, Singer LG, Tikkanen J, Martinu T. Risk assessment of chronic lung allograft dysfunction phenotypes: Validation and proposed refinement of the 2019 International Society for Heart and Lung Transplantation classification system. J Heart Lung Transplant 2020; 39:761-770. [DOI: 10.1016/j.healun.2020.04.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/14/2020] [Accepted: 04/12/2020] [Indexed: 12/26/2022] Open
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35
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Zhang CYK, Ahmed M, Huszti E, Levy L, Hunter SE, Boonstra KM, Moshkelgosha S, Sage AT, Azad S, Zamel R, Ghany R, Yeung JC, Crespin OM, Frankel C, Budev M, Shah P, Reynolds JM, Snyder LD, Belperio JA, Singer LG, Weigt SS, Todd JL, Palmer SM, Keshavjee S, Martinu T. Bronchoalveolar bile acid and inflammatory markers to identify high-risk lung transplant recipients with reflux and microaspiration. J Heart Lung Transplant 2020; 39:934-944. [PMID: 32487471 DOI: 10.1016/j.healun.2020.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a risk factor for chronic lung allograft dysfunction. Bile acids-putative markers of gastric microaspiration-and inflammatory proteins in the bronchoalveolar lavage (BAL) have been associated with chronic lung allograft dysfunction, but their relationship with GERD remains unclear. Although GERD is thought to drive chronic microaspiration, the selection of patients for anti-reflux surgery lacks precision. This multicenter study aimed to test the association of BAL bile acids with GERD, lung inflammation, allograft function, and anti-reflux surgery. METHODS We analyzed BAL obtained during the first post-transplant year from a retrospective cohort of patients with and without GERD, as well as BAL obtained before and after Nissen fundoplication anti-reflux surgery from a separate cohort. Levels of taurocholic acid (TCA), glycocholic acid, and cholic acid were measured using mass spectrometry. Protein markers of inflammation and injury were measured using multiplex assay and enzyme-linked immunosorbent assay. RESULTS At 3 months after transplantation, TCA, IL-1β, IL-12p70, and CCL5 were higher in the BAL of patients with GERD than in that of no-GERD controls. Elevated TCA and glycocholic acid were associated with concurrent acute lung allograft dysfunction and inflammatory proteins. The BAL obtained after anti-reflux surgery contained reduced TCA and inflammatory proteins compared with that obtained before anti-reflux surgery. CONCLUSIONS Targeted monitoring of TCA and selected inflammatory proteins may be useful in lung transplant recipients with suspected reflux and microaspiration to support diagnosis and guide therapy. Patients with elevated biomarker levels may benefit most from anti-reflux surgery to reduce microaspiration and allograft inflammation.
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Affiliation(s)
- Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sarah E Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kristen M Boonstra
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sassan Azad
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ricardo Zamel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Oscar M Crespin
- Division of General Surgery, University Health Network, University of Toronto, Toronto, Canada
| | | | | | - Pali Shah
- Johns Hopkins University Hospital, Baltimore, Maryland
| | | | | | | | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Jamie L Todd
- Duke University Medical Center, Durham, North Carolina
| | | | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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36
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Fuchs E, Levi L, Huszti EE, Picard BR, Berra G, Kawashima M, Takahagi A, Ghany R, Keshavjee S, Singer L, Tikkanen J, Martinu T. Significance of Phenotype Change Post CLAD-Onset on Allograft Survival. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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37
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Levy L, Moshkelgosha S, Huszti E, Hunter S, Renaud-Picard B, Berra G, Kawashima M, Takahagi A, Fernandez-Castillo J, Fuchs E, Ghany R, Keshavjee S, Singer L, Tikkanen J, Martinu T. Pulmonary Markers of Epithelial Cell Activation and Injury in Chronic Lung Allograft Dysfunction. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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38
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Levy L, Huszti E, Tikkanen J, Fernandez-Castillo J, Ghany R, Keshavjee S, Singer L, Husain S, Martinu T. Clinical Significance of Commensal Bacteria Isolated from Bronchoalveolar Lavage of Lung Transplant Recipients. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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39
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Darley D, Ma J, Levy L, Huszti E, Ghany R, Hutcheon M, Chow C, Tikkanen J, Keshavjee S, Singer L, Martinu T. Diffusing Capacity for Carbon Monoxide (DLCO) Trajectory in CLAD Phenotypes. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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40
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Levy L, Huszti E, Renaud-Picard B, Berra G, Kawashima M, Takahagi A, Ghany R, Moshkelgosha S, Keshavjee S, Singer L, Tikkanen J, Martinu T. Risk Assessment of Chronic Lung Allograft Dysfunction Phenotypes: Validation and Proposed Refinement of the 2019 ISHLT Classification System. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Levy L, Huszti E, Berra G, Renaud-Picard B, Kawashima M, Takahagi A, Moshkelgosha S, Ghany R, Chow C, Keshavjee S, Singer L, Tikkanen J, Martinu T. Forced Vital Capacity for Defining Restrictive Allograft Syndrome and Mixed Phenotype in Lung Transplant Recipients. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Belousova N, Ma J, Wu J, deHaas E, Vasileva A, Huang Q, Nadj R, Singer L, Keshavjee S, Ghany R, Martinu T, Tikkanen J, Cypel M, Ryan C, Chow C. Effects of Donor Smoking History on Early Post-Transplant Lung Function Measured by Oscillometry. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Levy L, Huszti E, Tikkanen J, Ghany R, Klement W, Ahmed M, Husain S, Fiset PO, Hwang D, Keshavjee S, Singer LG, Juvet S, Martinu T. The impact of first untreated subclinical minimal acute rejection on risk for chronic lung allograft dysfunction or death after lung transplantation. Am J Transplant 2020; 20:241-249. [PMID: 31397939 DOI: 10.1111/ajt.15561] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/14/2019] [Accepted: 07/26/2019] [Indexed: 01/25/2023]
Abstract
Acute cellular rejection (ACR) is a significant risk factor for chronic lung allograft dysfunction (CLAD). Although clinically manifest and higher grade (≥A2) ACR is generally treated with augmented immunosuppression, management of minimal (grade A1) ACR remains controversial. In our program, patients with subclinical and spirometrically stable A1 rejection (StA1R) are routinely not treated with augmented immunosuppression. We hypothesized that an untreated first StA1R does not increase the risk of CLAD or death compared to episodes of spirometrically stable no ACR (StNAR). The cohort was drawn from all consecutive adult, first, bilateral lung transplantations performed between 1999 and 2017. Biopsies obtained in the first-year posttransplant were paired with (forced expiratory volume in 1 second FEV1 ). The first occurrence of StA1R was compared to a time-matched StNAR. The risk of CLAD or death was assessed using univariable and multivariable Cox proportional hazards models. The analyses demonstrated no significant difference in risk of CLAD or death in patients with a first StA1R compared to StNAR. This largest study to date shows that, in clinically stable patients, an untreated first A1 ACR in the first-year posttransplant is not significantly associated with an increased risk for CLAD or death. Watchful-waiting approach may be an acceptable tactic for stable A1 episodes in lung transplant recipients.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - William Klement
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shahid Husain
- University Health Network Multi-Organ Transplant, University of Toronto, Toronto, ON
| | - Pierre O Fiset
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David Hwang
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
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Fernandez-Castillo J, Huszti E, Zhang K, Ghany R, Levy L, Darley D, Chaparro C, Tikkanen J, Keshavjee S, Singer L, Yeung J, Martinu T. A Combination of Delayed Gastric Emptying and Gastroesophageal Reflux Disease is Associated with Worse Outcomes in Lung Transplantation. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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