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Crutu A, Hanna A. [The role of surveillance bronchoscopy after lung transplantation]. Rev Mal Respir 2024; 41:59-68. [PMID: 37827927 DOI: 10.1016/j.rmr.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 08/23/2023] [Indexed: 10/14/2023]
Abstract
The role of surveillance bronchoscopy after lung transplantation. Lung transplantation is currently accepted as a potential treatment for end-stage respiratory diseases. That said, airway complications and the onset of chronic lung allograft dysfunction remain major causes of morbidity and mortality subsequent to lung transplantation and a significant obstacle to long-term survival. In this article, we discuss the advantages and limitations of bronchial endoscopy in post-lung transplant monitoring.
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Affiliation(s)
- A Crutu
- Service de chirurgie thoracique et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France.
| | - A Hanna
- Service de chirurgie thoracique et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
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2
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Boutin CA, Ison MG. Systematic fungal biomarker or polymerase chain reaction testing in lung transplant recipients: Retrospective analysis to optimize their use. Transpl Infect Dis 2023; 25:e14136. [PMID: 37608632 PMCID: PMC10798658 DOI: 10.1111/tid.14136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/28/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Among lung transplant recipients, serial bronchoscopies are performed frequently. Often, serial galactomannan (GM), 1,3-β-d-glucan (BDG), and Pneumocystis jirovecii (PJ) testing is performed with these broncho-alveolar lavages (BALs) as standard of care with limited data to support their routine use. METHODS After Institutional Review Board approval, we retrospectively collected all blood and BAL GM, BDG, and PJ test results from January 2015 to July 20, 2022. Primary data collection from the Northwestern Medicine EDW was supplemented by manual chart review. RESULTS During the study period, 236 lung transplant recipients were cared for by our center. Of these patients, 217 (91.9%) had 1418 GM tests performed; 61 (4.3%) were positive (index ≥1). Fungal cultures were requested for most BAL-GM (90.7%). Out of duplicates in same BAL, results discrepancy was minimal (3.4%). 172 (72.9%) had BDG tests were performed; 25.6% were positive. Thirteen patients had multiple BDG during one hospitalization (mean 2.3 tests); none of the negative test repeated became positive. Eleven negative BDG were seen in patients with invasive aspergillosis (IA). Note that, 577 PJ testing were performed (direct fluorescent antibody [n = 494] or polymerase chain reaction [PCR] [n = 80], or both [n = 3]) in 174 different patients. None were positive. CONCLUSION Despite supplemental GM, BDG, and Pneumocystis jirovecii pneumonia PCR being performed routinely on lung transplant recipients undergoing BAL at our center, the data suggests a more tailored approach may be appropriate. There is no role for routine serial testing with these assays during a single hospitalization. BDG confers no added-value over GM with cultures for IA diagnosis.
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Affiliation(s)
- Catherine-Audrey Boutin
- Department of Medicine, Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medicine, Division of Infectious Disease, University of Montreal Hospital Center, Montreal, Canada
| | - Michael G Ison
- Respiratory Diseases Branch, Division of Microbiology and Infectious Diseases, NIAID, NIH, Rockville, Maryland, USA
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3
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Keating DT, Taverner J. Transbronchial cryobiopsy in lung transplantation: risk, reward and relevance. Eur Respir J 2023; 61:61/1/2201942. [PMID: 36609523 DOI: 10.1183/13993003.01942-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/06/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Dominic Thomas Keating
- Respiratory Department, Alfred Hospital, Melbourne, Australia
- Monash University, Clayton, Australia
| | - John Taverner
- Respiratory Department, Alfred Hospital, Melbourne, Australia
- Monash University, Clayton, Australia
- Royal Brompton and Harefield Hospitals London, London, UK
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4
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Dillon WP, Acosta TP, Failla A, Corrales J, Alangaden G, Ramesh M. Utility of microbiologic testing in surveillance bronchoscopy following lung transplantation: A retrospective cohort study. Transpl Infect Dis 2022; 24:e13989. [PMID: 36380574 DOI: 10.1111/tid.13989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The utility of surveillance bronchoscopy (SB) for the clinical management of lung transplant recipients (LTRs) is undefined. This study evaluates the role of SB in the monitoring and care of LTRs. METHODS We retrospectively analyzed all LTRs who had SB at Henry Ford Hospital in Detroit, Michigan between August 2014 and August 2019. Bronchoscopies performed for clinical symptoms, new radiographic abnormalities, and to assess stents or acute rejection were excluded. A total of 107 LTRs and 449 bronchoscopies were analyzed. The primary outcome was the rate of change in clinical care based on microbiologic and pathologic test results. Secondary outcomes were rates of microbiologic and pathologic test positivity and rates of adverse effects. RESULTS The most common microbiologic tests performed on bronchoalveolar lavage were bacterial (96.9%), fungal (95.3%), and acid-fast bacillus (95.1%) stains and cultures. Of 2560 microbiologic tests, 22.0% were positive and resulted in therapy changes for 2.9%. Positive galactomannan, acid-fast bacillus tests, and Pneumocystis jirovecii antigen/polymerase chain reaction did not result in therapy changes. Of the 370 transbronchial biopsies performed, 82.2% were negative for acute rejection and 13% were positive for A1/A2 rejection. Immunosuppressive therapy changes occurred after 15.8% with reduction in immunosuppression due to positive microbiologic tests in 16.9%. Adverse events occurred in 8.0% of patients. CONCLUSION Diagnostic stewardship is warranted when performing SB in LTRs.
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Affiliation(s)
- William P Dillon
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Tommy Parraga Acosta
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Andrew Failla
- Division of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Julio Corrales
- Division of Pulmonary Medicine and Critical Care, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - George Alangaden
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mayur Ramesh
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan, USA
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5
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Rosenheck J, Keller B, Fehringer G, Demko Z, Bohrade S, Ross D. Why Cell-Free DNA Can Be a “Game Changer” for Lung Allograft Monitoring for Rejection and Infection. CURRENT PULMONOLOGY REPORTS 2022; 11:75-85. [PMID: 35910533 PMCID: PMC9315332 DOI: 10.1007/s13665-022-00292-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 02/06/2023]
Abstract
Purpose of Review Although there has been improvement in short-term clinical outcomes for patients following lung transplant (LT), advances have not translated into longer-term allograft survival. Furthermore, invasive biopsies are still standard of practice for monitoring LT recipients for allograft injury. We review the relevant literature supporting the role of using plasma donor-derived cell-free DNA (dd-cfDNA) as a non-invasive biomarker for LT allograft injury surveillance and discuss future research directions. Recent Findings Accumulating data has demonstrated that dd-cfDNA is associated with molecular and cellular injury due to acute (cellular and antibody-mediated) rejection, chronic lung allograft dysfunction, and relevant infectious pathogens. Strong performance in distinguishing rejection and allograft injury from stable patients has set the stage for clinical trials to assess dd-cfDNA utility for surveillance of LT patients. Research investigating the potential role of dd-cfDNA methylation signatures to map injured tissue and cell-free DNA in detecting allograft injury-related pathogens is ongoing. Summary There is an amassed breadth of clinical data to support a role for dd-cfDNA in monitoring rejection and other forms of allograft injury. Rigorously designed, robust clinical trials that encompass the diversity in patient demographics are paramount to furthering our understanding and adoption of plasma dd-cfDNA for surveillance of lung allograft health.
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Affiliation(s)
- J.P. Rosenheck
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH USA
| | - B.C. Keller
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA USA
| | - G. Fehringer
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
| | - Z.P. Demko
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
| | - S.M. Bohrade
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
| | - D.J. Ross
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
- Lung Transplant & Molecular Diagnostics, Natera, Inc, San Carlos, CA USA
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Habertheuer A, Ram C, Schmierer M, Chatterjee S, Hu R, Freas A, Zielinski P, Rogers W, Silvestro EM, McGrane M, Moore JS, Korutla L, Siddiqui S, Xin Y, Rizi R, Qin Tao J, Kreisel D, Naji A, Ochiya T, Vallabhajosyula P. Circulating Donor Lung-specific Exosome Profiles Enable Noninvasive Monitoring of Acute Rejection in a Rodent Orthotopic Lung Transplantation Model. Transplantation 2022; 106:754-766. [PMID: 33993180 DOI: 10.1097/tp.0000000000003820] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a critical need for development of biomarkers to noninvasively monitor for lung transplant rejection. We investigated the potential of circulating donor lung-specific exosome profiles for time-sensitive diagnosis of acute rejection in a rat orthotopic lung transplant model. METHODS Left lungs from Wistar transgenic rats expressing human CD63-GFP, an exosome marker, were transplanted into fully MHC-mismatched Lewis recipients or syngeneic controls. Recipient blood was collected between 4 h and 10 d after transplantation, and plasma was processed for exosome isolation by size exclusion column chromatography and ultracentrifugation. Circulating donor exosomes were profiled using antihuman CD63 antibody quantum dot on the nanoparticle detector and via GFP trigger on the nanoparticle flow cytometer. RESULTS In syngeneic controls, steady-state levels of circulating donor exosomes were detected at all posttransplant time points. Allogeneic grafts lost perfusion by day 8, consistent with acute rejection. Levels of circulating donor exosomes peaked on day 1, decreased significantly by day 2, and then reached baseline levels by day 3. Notably, decrease in peripheral donor exosome levels occurred before grafts had histological evidence of acute rejection. CONCLUSIONS Circulating donor lung-specific exosome profiles enable an early detection of acute rejection before histologic manifestation of injury to the pulmonary allograft. As acute rejection episodes are a major risk factor for the development of chronic lung allograft dysfunction, this biomarker may provide a novel noninvasive diagnostic platform that can translate into earlier therapeutic intervention for lung transplant patients.
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Affiliation(s)
- Andreas Habertheuer
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Chirag Ram
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Shampa Chatterjee
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robert Hu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrew Freas
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Patrick Zielinski
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Wade Rogers
- Still Pond Cytomics LLC, West Chester, PA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Eva M Silvestro
- Still Pond Cytomics LLC, West Chester, PA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Jonni S Moore
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Laxminarayana Korutla
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rahim Rizi
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jian Qin Tao
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Daniel Kreisel
- Departments of Surgery, Pathology & Immunology, Washington University, St. Louis, MI
| | - Ali Naji
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Takahiro Ochiya
- Department of Molecular and Cellular Medicine, Tokyo Medical University, Tokyo, Japan
| | - Prashanth Vallabhajosyula
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
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7
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Subramani MV, Pandit S, Gadre SK. Acute rejection and post lung transplant surveillance. Indian J Thorac Cardiovasc Surg 2022; 38:271-279. [PMID: 35340687 PMCID: PMC8938213 DOI: 10.1007/s12055-021-01320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose The purpose of this review is to summarize the current evidence on the evaluation and treatment of acute rejection after lung transplantation. Results Despite significant progress in the field of transplant immunology, acute rejection remains a frequent complication after transplantation. Almost 30% of lung transplant recipients experience at least one episode of acute cellular rejection (ACR) during the first year after transplant. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well-defined histopathologic diagnostic criteria and grading. The diagnosis of antibody-mediated rejection after lung transplantation requires a multidisciplinary approach. Antibody-mediated rejection may cause acute allograft failure. Conclusions Acute rejection is a risk factor for development of chronic rejection. Further investigations are required to better define risk factors, surveillance strategies, and optimal management strategies for acute allograft rejection.
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Affiliation(s)
| | - Sumir Pandit
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Shruti Kumar Gadre
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
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8
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Keller M, Sun J, Mutebi C, Shah P, Levine D, Aryal S, Iacono A, Timofte I, Mathew J, Varghese A, Giner C, Agbor-Enoh S. Donor-derived cell-free DNA as a composite marker of acute lung allograft dysfunction in clinical care. J Heart Lung Transplant 2021; 41:458-466. [DOI: 10.1016/j.healun.2021.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/07/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022] Open
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9
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Cystic fibrosis foundation consensus statements for the care of cystic fibrosis lung transplant recipients. J Heart Lung Transplant 2021; 40:539-556. [PMID: 34103223 DOI: 10.1016/j.healun.2021.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 12/27/2022] Open
Abstract
Cystic fibrosis (CF) is the indication for transplantation in approximately 15% of recipients worldwide, and Cystic Fibrosis Lung Transplant Recipients (CFLTRs) have excellent long-term outcomes. Yet, CFLTRs have unique comorbidities that require specialized care. The objective of this document is to provide recommendations to CF and lung transplant clinicians for the management of perioperative and underlying comorbidities of CFLTRs and the impact of transplantation on these comorbidities. The Cystic Fibrosis Foundation (CFF) organized a multidisciplinary committee to develop CF Lung Transplant Clinical Care Recommendations. Three workgroups were formed to develop focused questions. Following a literature search, consensus recommendations were developed by the committee members based on literature review, committee experience and iterative revisions, and in response to public comment. The committee formulated 32 recommendation statements in the topics related to infectious disease, endocrine, gastroenterology, pharmacology, mental health and family planning. Broadly, the committee recommends close coordination of care between the lung transplant team, the cystic fibrosis care center, and specialists in other disciplines with experience in the care of CF and lung transplant recipients. These consensus statements will help lung transplant providers care for CFLTRs in order to improve post-transplant outcomes in this population.
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10
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Shah P, Lowery E, Chaparro C, Visner G, Hempstead SE, Abraham J, Bhakta Z, Carroll M, Christon L, Danziger-Isakov L, Diamond JM, Lease E, Leonard J, Litvin M, Poole R, Vlahos F, Werchan C, Murray MA, Tallarico E, Faro A, Pilewski JM, Hachem RR. DUPLICATE: Cystic Fibrosis Foundation Consensus Statements for the Care of Cystic Fibrosis Lung Transplant Recipients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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11
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Glanville AR. Pseudomonas and risk factor mitigation for chronic lung allograft dysfunction. Eur Respir J 2020; 56:56/4/2001968. [DOI: 10.1183/13993003.01968-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/22/2020] [Indexed: 11/05/2022]
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12
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Frye BC, Gasplmayr M, Hettich I, Zissel G, Müller-Quernheim J. Surveillance Bronchoscopy for the Care of Lung Transplant Recipients: A Retrospective Single Center Analysis. Transplant Proc 2020; 53:265-272. [PMID: 32981692 DOI: 10.1016/j.transproceed.2020.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/30/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lung transplantation is often the only treatment for end-stage lung disease. Following lung transplantation, infections and transplant rejections are major obstacles to short- and long-term success. Therefore, close monitoring for these complications is required after lung transplantation. The role of prescheduled surveillance bronchoscopies after lung transplantation is controversial. Thus, we aimed to retrospectively analyze the therapeutic implications of surveillance bronchoscopies in 110 consecutive lung transplant recipients. MATERIALS AND METHODS Results of 400 prescheduled surveillance bronchoscopies of 110 consecutive lung transplant recipients were analyzed. Positive results (pathologic histology, microbiology, or virology) were further investigated for their effect on clinical decision making. Additionally, cellular composition of bronchoalveolar lavage (BAL) was analyzed. RESULTS Two hundred five surveillance bronchoscopies showed pathologic findings. In 81 cases clinical treatment was changed based on the results. That is, 20% of all prescheduled bronchoscopies directly influenced clinical decision making. Furthermore, analyses of BAL indicate that increased alveolar eosinophils are associated with an increased risk of transplant rejection. CONCLUSIONS Prescheduled surveillance bronchoscopies identify clinically unsuspected but therapeutically relevant pathologic findings in approximately 20% of cases. BAL cell composition may confer additional information, especially in cases when biopsy is not possible.
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Affiliation(s)
- Björn Christian Frye
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Markus Gasplmayr
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ina Hettich
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gernot Zissel
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joachim Müller-Quernheim
- Department of Pneumology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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13
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Cho E, Wu JKY, Birriel DC, Matelski J, Nadj R, DeHaas E, Huang Q, Yang K, Xu T, Cheung AB, Woo LN, Day L, Cypel M, Tikkanen J, Ryan C, Chow CW. Airway Oscillometry Detects Spirometric-Silent Episodes of Acute Cellular Rejection. Am J Respir Crit Care Med 2020; 201:1536-1544. [PMID: 32135068 DOI: 10.1164/rccm.201908-1539oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Acute cellular rejection (ACR) is common during the initial 3 months after lung transplant. Patients are monitored with spirometry and routine surveillance transbronchial biopsies. However, many centers monitor patients with spirometry only because of the risks and insensitivity of transbronchial biopsy for detecting ACR. Airway oscillometry is a lung function test that detects peripheral airway inhomogeneity with greater sensitivity than spirometry. Little is known about the role of oscillometry in patient monitoring after a transplant.Objectives: To characterize oscillometry measurements in biopsy-proven clinically significant (grade ≥2 ACR) in the first 3 months after a transplant.Methods: We enrolled 156 of the 209 double lung transplant recipients between December 2017 and March 2019. Weekly outpatient oscillometry and spirometry and surveillance biopsies at Weeks 6 and 12 were conducted at our center.Measurements and Main Results: Of the 138 patients followed for 3 or more months, 15 patients had 16 episodes of grade 2 ACR (AR2) and 44 patients had 64 episodes of grade 0 ACR (AR0) rejection associated with stable and/or improving spirometry. In 15/16 episodes of AR2, spirometry was stable or improving in the weeks leading to transbronchial biopsy. However, oscillometry was markedly abnormal and significantly different from AR0 (P < 0.05), particularly in integrated area of reactance and the resistance between 5 and 19 Hz, the indices of peripheral airway obstruction. By 2 weeks after biopsy, after treatment for AR2, oscillometry in the AR2 group improved and was similar to the AR0 group.Conclusions: Oscillometry identified physiological changes associated with AR2 that were not discernible by spirometry and is useful for graft monitoring after a lung transplant.
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Affiliation(s)
- Elizabeth Cho
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joyce K Y Wu
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Pulmonary Function Laboratory
| | - Daniella Cunha Birriel
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Programme, Multi-Organ Transplant Unit
| | | | - Richard Nadj
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emily DeHaas
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Qian Huang
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Yang
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tong Xu
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Aloysius B Cheung
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay N Woo
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Day
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Pulmonary Function Laboratory
| | - Marcelo Cypel
- Toronto Lung Transplant Programme, Multi-Organ Transplant Unit.,Division of Thoracic Surgery, Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Programme, Multi-Organ Transplant Unit
| | - Clodagh Ryan
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Pulmonary Function Laboratory
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Programme, Multi-Organ Transplant Unit
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14
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Todd JL, Neely ML, Kopetskie H, Sever ML, Kirchner J, Frankel CW, Snyder LD, Pavlisko EN, Martinu T, Tsuang W, Shino MY, Williams N, Robien MA, Singer LG, Budev M, Shah PD, Reynolds JM, Palmer SM, Belperio JA, Weigt SS. Risk Factors for Acute Rejection in the First Year after Lung Transplant. A Multicenter Study. Am J Respir Crit Care Med 2020; 202:576-585. [PMID: 32379979 PMCID: PMC7427399 DOI: 10.1164/rccm.201910-1915oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 05/07/2020] [Indexed: 11/16/2022] Open
Abstract
Rationale: Acute rejection, manifesting as lymphocytic inflammation in a perivascular (acute perivascular rejection [AR]) or peribronchiolar (lymphocytic bronchiolitis [LB]) distribution, is common in lung transplant recipients and increases the risk for chronic graft dysfunction.Objectives: To evaluate clinical factors associated with biopsy-proven acute rejection during the first post-transplant year in a present-day, five-center lung transplant cohort.Methods: We analyzed prospective diagnoses of AR and LB from over 2,000 lung biopsies in 400 newly transplanted adult lung recipients. Because LB without simultaneous AR was rare, our analyses focused on risk factors for AR. Multivariable Cox proportional hazards models were used to assess donor and recipient factors associated with the time to the first AR occurrence.Measurements and Main Results: During the first post-transplant year, 53.3% of patients experienced at least one AR episode. Multivariable proportional hazards analyses accounting for enrolling center effects identified four or more HLA mismatches (hazard ratio [HR], 2.06; P ≤ 0.01) as associated with increased AR hazards, whereas bilateral transplantation (HR, 0.57; P ≤ 0.01) was associated with protection from AR. In addition, Wilcoxon rank-sum analyses demonstrated bilateral (vs. single) lung recipients, and those with fewer than four (vs. more than four) HLA mismatches demonstrated reduced AR frequency and/or severity during the first post-transplant year.Conclusions: We found a high incidence of AR in a contemporary multicenter lung transplant cohort undergoing consistent biopsy sampling. Although not previously recognized, the finding of reduced AR in bilateral lung recipients is intriguing, warranting replication and mechanistic exploration.
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Affiliation(s)
- Jamie L. Todd
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Duke Clinical Research Institute, and
| | | | | | | | | | - Courtney W. Frankel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Laurie D. Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Duke Clinical Research Institute, and
| | | | - Tereza Martinu
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Nikki Williams
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Mark A. Robien
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Lianne G. Singer
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - John M. Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Scott M. Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Duke Clinical Research Institute, and
| | | | - S. Sam Weigt
- University of California Los Angeles, Los Angeles, California
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15
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Martinu T, Koutsokera A, Benden C, Cantu E, Chambers D, Cypel M, Edelman J, Emtiazjoo A, Fisher AJ, Greenland JR, Hayes D, Hwang D, Keller BC, Lease ED, Perch M, Sato M, Todd JL, Verleden S, von der Thüsen J, Weigt SS, Keshavjee S. International Society for Heart and Lung Transplantation consensus statement for the standardization of bronchoalveolar lavage in lung transplantation. J Heart Lung Transplant 2020; 39:1171-1190. [PMID: 32773322 PMCID: PMC7361106 DOI: 10.1016/j.healun.2020.07.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 01/09/2023] Open
Abstract
Bronchoalveolar lavage (BAL) is a key clinical and research tool in lung transplantation (LTx). However, BAL collection and processing are not standardized across LTx centers. This International Society for Heart and Lung Transplantation-supported consensus document on BAL standardization aims to clarify definitions and propose common approaches to improve clinical and research practice standards. The following 9 areas are covered: (1) bronchoscopy procedure and BAL collection, (2) sample handling, (3) sample processing for microbiology, (4) cytology, (5) research, (6) microbiome, (7) sample inventory/tracking, (8) donor bronchoscopy, and (9) pediatric considerations. This consensus document aims to harmonize clinical and research practices for BAL collection and processing in LTx. The overarching goal is to enhance standardization and multicenter collaboration within the international LTx community and enable improvement and development of new BAL-based diagnostics.
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Affiliation(s)
- Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Angela Koutsokera
- Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Lung Transplant Program, Division of Pulmonology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Edward Cantu
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel Chambers
- Lung Transplant Program, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Marcelo Cypel
- Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Edelman
- Lung Transplant Program, Puget Sound VA Medical Center, Seattle, Washington
| | - Amir Emtiazjoo
- Lung Transplant Program, University of Florida, Gainesville, Florida
| | - Andrew J Fisher
- Institute of Transplantation, Newcastle Upon Tyne Hospitals and Newcastle University, United Kingdom
| | - John R Greenland
- Department of Medicine, VA Health Care System, San Francisco, California
| | - Don Hayes
- Lung Transplant Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Hwang
- Department of Pathology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Brian C Keller
- Lung Transplant Program, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Erika D Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Michael Perch
- Lung Transplant Program, Rigshospitalet, Copenhagen, Denmark
| | - Masaaki Sato
- Department of Surgery, University of Tokyo, Tokyo, Japan
| | - Jamie L Todd
- Lung Transplant Program, Duke University Medical Center, Durham, North Carolina
| | - Stijn Verleden
- Laboratory of Pneumology, Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - S Samuel Weigt
- Lung Transplant Program, University of California Los Angeles, Los Angeles, California
| | - Shaf Keshavjee
- Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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16
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Takizawa DB, de Castro CCB, Paiva MA, Campos SV, Carraro RM, Costa AN, do Nascimento ECT, Samano MN, de Oliveira Braga Teixeira RH. Surveillance Bronchoscopy in Lung Transplantation Recipients: A Single Center Experience Analysis. Transplant Proc 2020; 52:1380-1383. [PMID: 32253000 DOI: 10.1016/j.transproceed.2020.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 10/24/2022]
Abstract
Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy is the gold standard for the diagnosis of infection or acute cellular rejection in lung transplantation (LTx) recipients, but there is some controversy to perform it in asymptomatic patients. We conducted a retrospective analysis of medical reports of LTx recipients who survived in the first year after transplant during the period of August 2003 to February 2018 to evaluate the applicability of this procedure in the management of asymptomatic acute cellular rejection in our center. We assessed 1252 bronchoscopies of 247 patients during this period, and, facing the histopathological results, we defined our management that included conservative or intervention therapy. In our service the information obtained by surveillance bronchoscopy was sufficient to modify the management mainly in the first 2 surveillance bronchoscopies (second and sixth week post LTx). This effect seems to dilute after the second month, making its applicability more questionable.
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Affiliation(s)
- Daniel B Takizawa
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Caio C B de Castro
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Michelle A Paiva
- Medicine student in Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Silvia V Campos
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Rafael M Carraro
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - André N Costa
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Ellen C T do Nascimento
- Pathology Department, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Marcos N Samano
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Ricardo H de Oliveira Braga Teixeira
- Lung Transplantation Group, Instituto do Coração (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil.
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17
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Greer M, Werlein C, Jonigk D. Surveillance for acute cellular rejection after lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:410. [PMID: 32355854 PMCID: PMC7186718 DOI: 10.21037/atm.2020.02.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute cellular rejection (ACR) is a common complication following lung transplantation (LTx), affecting almost a third of recipients in the first year. Established, comprehensive diagnostic criteria exist but they necessitate allograft biopsies which in turn increases clinical risk and can pose certain logistical and economic problems in service delivery. Undermining these challenges further, are known problems with inter-observer interpretation of biopsies and uncertainty as to the long-term implications of milder or indeed asymptomatic episodes. Increased risk of chronic lung allograft dysfunction (CLAD) has long been considered the most significant consequence of ACR. Consensus is lacking as to whether this applies to mild ACR, with contradictory evidence available. Given these issues, research into alternative, minimal or non-invasive biomarkers represents the main focus of research in ACR. A number of potential markers have been proposed, but none to date have demonstrated adequate sensitivity and specificity to allow translation from bench to bedside.
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Affiliation(s)
- Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany
| | | | - Danny Jonigk
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany.,Institute for Pathology, Hannover Medical School, Hannover, Germany
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18
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Parulekar AD, Kao CC. Detection, classification, and management of rejection after lung transplantation. J Thorac Dis 2019; 11:S1732-S1739. [PMID: 31632750 DOI: 10.21037/jtd.2019.03.83] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well defined histopathologic diagnostic criteria and grading. Diagnosis of AMR requires a multidisciplinary approach. CLAD is the major barrier to long-term survival following lung transplantation. The most common phenotype of CLAD is bronchiolitis obliterans syndrome (BOS) which is defined by a persistent obstructive decline in lung function. Restrictive allograft dysfunction (RAS) is a second phenotype of CLAD and is associated with a worse prognosis. This article will review the diagnosis, staging, clinical presentation, and treatment of acute rejection, AMR, and CLAD following lung transplantation.
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Affiliation(s)
- Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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19
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Solidoro P, Corbetta L, Patrucco F, Sorbello M, Piccioni F, D'amato L, Renda T, Petrini F. Competences in bronchoscopy for Intensive Care Unit, anesthesiology, thoracic surgery and lung transplantation. Panminerva Med 2019; 61:367-385. [DOI: 10.23736/s0031-0808.18.03565-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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20
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Halloran KM, Parkes MD, Chang J, Timofte IL, Snell GI, Westall GP, Hachem R, Kreisel D, Trulock E, Roux A, Juvet S, Keshavjee S, Jaksch P, Klepetko W, Halloran PF. Molecular assessment of rejection and injury in lung transplant biopsies. J Heart Lung Transplant 2019; 38:504-513. [PMID: 30773443 DOI: 10.1016/j.healun.2019.01.1317] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Improved understanding of lung transplant disease states is essential because failure rates are high, often due to chronic lung allograft dysfunction. However, histologic assessment of lung transplant transbronchial biopsies (TBBs) is difficult and often uninterpretable even with 10 pieces. METHODS We prospectively studied whether microarray assessment of single TBB pieces could identify disease states and reduce the amount of tissue required for diagnosis. By following strategies successful for heart transplants, we used expression of rejection-associated transcripts (annotated in kidney transplant biopsies) in unsupervised machine learning to identify disease states. RESULTS All 242 single-piece TBBs produced reliable transcript measurements. Paired TBB pieces available from 12 patients showed significant similarity but also showed some sampling variance. Alveolar content, as estimated by surfactant transcript expression, was a source of sampling variance. To offset sampling variation, for analysis, we selected 152 single-piece TBBs with high surfactant transcripts. Unsupervised archetypal analysis identified 4 idealized phenotypes (archetypes) and scored biopsies for their similarity to each: normal; T-cell‒mediated rejection (TCMR; T-cell transcripts); antibody-mediated rejection (ABMR)-like (endothelial transcripts); and injury (macrophage transcripts). Molecular TCMR correlated with histologic TCMR. The relationship of molecular scores to histologic ABMR could not be assessed because of the paucity of ABMR in this population. CONCLUSIONS Molecular assessment of single-piece TBBs can be used to classify lung transplant biopsies and correlated with rejection histology. Two or 3 pieces for each TBB will probably be needed to offset sampling variance.
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Affiliation(s)
- Kieran M Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Parkes
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Irina L Timofte
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland at Baltimore, Baltimore, Maryland, USA
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital, Monash University, Melbourne, Australia
| | - Glen P Westall
- Lung Transplant Service, Alfred Hospital, Monash University, Melbourne, Australia
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Elbert Trulock
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Antoine Roux
- Service de Pneumologie, Hôpital Foch, Suresnes, France
| | - Stephen Juvet
- Department of Medicine University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Department of Medicine University Health Network, Toronto, Ontario, Canada
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada.
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21
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Tosi D, Carrinola R, Morlacchi LC, Tarsia P, Rossetti V, Mendogni P, Rosso L, Righi I, Damarco F, Nosotti M. Surveillance Transbronchial Biopsy Program to Evaluate Acute Rejection After Lung Transplantation: A Single Institution Experience. Transplant Proc 2018; 51:198-201. [PMID: 30655138 DOI: 10.1016/j.transproceed.2018.04.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/13/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is no unanimity in the literature regarding the value of transbronchial biopsies (TBBs) performed at a scheduled time after lung transplantation (surveillance TBBs [SBs]), compared to biopsies performed for suspected clinical acute rejection (clinically indicated TBBs [CIBs]). This study exposes an assessment of our experience over the last 4 years through a retrospective analysis of the data collected. METHODS In our center, SBs are performed at 3, 6, and 12 months after a transplant. Data from 110 patients who underwent a TBB were collected from January 2013 to November 2017. Clinical and functional data along with the histologic results and complications were collected. RESULTS Overall 251 procedures were performed: 223 for surveillance purposes and 28 for clinical indications. The SBs diagnostic rate was 84%. A grade 2 acute rejection (AR) was detected in 9 asymptomatic patients, all of whom were medically treated, with downgrading of AR documented in all cases. The rate of medical intervention in the SB group was 8%. The CIBs diagnostic rate was 96%. The rate of AR detected by CIBs was significantly higher than by SBs (36% versus 4%; P < .0001). Overall the major complication rate was 4%; no patients required transfusions and no mortality occurred in the patient cohort. CONCLUSIONS The surveillance protocol did not eliminate the necessity of CIBs, but in 8% of patients early rejection was histologically assessed. The correlation between histologic and clinical data allows a more careful approach to transplanted patients.
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Affiliation(s)
- D Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - R Carrinola
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L C Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Adult Cystic Fibrosis Center, Respiratory Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - P Tarsia
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Adult Cystic Fibrosis Center, Respiratory Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - V Rossetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Adult Cystic Fibrosis Center, Respiratory Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - P Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - I Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Damarco
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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22
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Abstract
Despite induction immunosuppression and the use of aggressive maintenance immunosuppressive regimens, acute allograft rejection following lung transplantation is still a problem with important diagnostic and therapeutic challenges. As well as causing early graft loss and mortality, acute rejection also initiates the chronic alloimmune responses and airway-centred inflammation that predispose to bronchiolitis obliterans syndrome (BOS), also known as chronic lung allograft dysfunction (CLAD), which is a major source of morbidity and mortality after lung transplantation. Cellular responses to human leukocyte antigens (HLAs) on the allograft have traditionally been considered the main mechanism of acute rejection, but the influence of humoral immunity is increasingly recognised. As with other several other solid organ transplants, antibody-mediated rejection (AMR) is now a well-accepted and distinct clinical entity in lung transplantation. While acute cellular rejection (ACR) has defined histopathological criteria, transbronchial biopsy is less useful in AMR and its diagnosis is complicated by challenges in the measurement of antibodies directed against donor HLA, and a determination of their significance. Increasing awareness of the importance of non-HLA antigens further clouds this issue. Here, we review the pathophysiology, diagnosis, clinical presentation and treatment of ACR and AMR in lung transplantation, and discuss future potential biomarkers of both processes that may forward our understanding of these conditions.
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Affiliation(s)
- Mark Benzimra
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - Greg L Calligaro
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Allan R Glanville
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
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23
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Kapnadak SG, Kicska GA, Ramos KJ, Marshall DA, Carroll TY, Pipavath SN, Mulligan MS, Goss CH, Aitken ML. Tracheal diverticula in advanced cystic fibrosis: Prevalence, features, and outcomes after lung transplantation. J Cyst Fibros 2017; 16:735-743. [PMID: 28757079 DOI: 10.1016/j.jcf.2017.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tracheal diverticula (TD) are rare anomalies that may harbor infected secretions, posing potential risk to patients with lung disease. In an end-stage cystic fibrosis (CF) cohort, we describe the characteristics and associated post-lung transplant (LTx) outcomes of TD. METHODS Pre-transplant computed tomography (CT)'s were reviewed in CF patients undergoing LTx. TD were characterized radiographically and on autopsy when available. Pre-transplant clinical variables and post-transplant outcomes were compared by TD status. RESULTS Of 93 patients, 35 (37.6%) had TD. 58% of TD had fat-stranding, and post-mortem TD examinations revealed histology carrying intense submucosal inflammation, and purulent contents that cultured identical species to sputum. There was no difference in post-LTx survival [HR 1.77 (0.82-3.82), p=0.147], bacterial re-colonization, or rejection in patients with TD compared to those without. Patients with TD were more likely to die from infection, but the result was not statistically significant [HR 2.02 (0.62-6.63), p=0.245]. CONCLUSIONS We found a high prevalence of TD in end-stage CF, where diverticula may represent a large-airway bacterial reservoir. TD were not associated with differences in post-LTx outcomes, but given the infectious concerns further investigation is necessary.
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Affiliation(s)
- Siddhartha G Kapnadak
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Gregory A Kicska
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Desiree A Marshall
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Tamara Y Carroll
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Sudhakar N Pipavath
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States; Department of Pediatrics, Division of Pediatric Pulmonology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Moira L Aitken
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
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24
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Donor-Reactive Regulatory T Cell Frequency Increases During Acute Cellular Rejection of Lung Allografts. Transplantation 2017; 100:2090-8. [PMID: 27077597 DOI: 10.1097/tp.0000000000001191] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute cellular rejection is a major cause of morbidity after lung transplantation. Because regulatory T (Treg) cells limit rejection of solid organs, we hypothesized that donor-reactive Treg increase after transplantation with development of partial tolerance and decrease relative to conventional CD4 (Tconv) and CD8 T cells during acute cellular rejection. METHODS To test these hypotheses, we prospectively collected 177 peripheral blood mononuclear cell specimens from 39 lung transplant recipients at the time of transplantation and during bronchoscopic assessments for acute cellular rejection. We quantified the proportion of Treg, CD4 Tconv, and CD8 T cells proliferating in response to donor-derived, stimulated B cells. We used generalized estimating equation-adjusted regression to compare donor-reactive T cell frequencies with acute cellular rejection pathology. RESULTS An average of 16.5 ± 9.0% of pretransplantation peripheral blood mononuclear cell Treg cell were donor-reactive, compared with 3.8% ± 2.9% of CD4 Tconv and 3.4 ± 2.6% of CD8 T cells. These values were largely unchanged after transplantation. Donor-reactive CD4 Tconv and CD8 T cell frequencies both increased 1.5-fold (95% confidence interval [95% CI], 1.3-1.6; P < 0.001 and 95% CI, 1.2-1.6; P = 0.007, respectively) during grade A2 rejection compared with no rejection. Surprisingly, donor-reactive Treg frequencies increased by 1.7-fold (95% CI, 1.4-1.8; P < 0.001). CONCLUSIONS Contrary to prediction, overall proportions of donor-reactive Treg cells are similar before and after transplantation and increase during grade A2 rejection. This suggests how A2 rejection can be self-limiting. The observed increases over high baseline proportions in donor-reactive Treg were insufficient to prevent acute lung allograft rejection.
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25
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Lung Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7153460 DOI: 10.1007/978-3-319-29683-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.
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26
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Wong JY, Westall GP, Snell GI. Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients. Pediatr Pulmonol 2015; 50:1406-19. [PMID: 25940429 DOI: 10.1002/ppul.23203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 12/19/2022]
Abstract
Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.
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Affiliation(s)
- Jackson Y Wong
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Glen P Westall
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
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27
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Inoue M, Minami M, Wada N, Nakagiri T, Funaki S, Kawamura T, Shintani Y, Okumura M. Results of surveillance bronchoscopy after cadaveric lung transplantation: a Japanese single-institution study. Transplant Proc 2015; 46:944-7. [PMID: 24767387 DOI: 10.1016/j.transproceed.2013.10.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 10/01/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND The prevention and early detection of post-transplantation rejection and infection are key clinical points to achieve long-term survival after lung transplantation. Although surveillance bronchoscopy (SB) is performed in many transplantation centers, it is still controversial because of its undefined clinical significance and its possible complications. We evaluated the clinical utility of SB after cadaveric lung transplantation in Japan, where bilateral transplantation is officially limited to patients medically requiring bilateral grafts. PATIENTS AND METHODS Twenty-eight patients who underwent cadaveric lung transplantation followed by SB were retrospectively analyzed with reference to the results of bronchoscopy. SB is routinely performed at 1, 2, 3, 6, and 12 months after lung transplantation and annually thereafter. Clinically indicated bronchoscopy (CIB) is considered in patients with suspected rejection or airway infection, and for follow-up examination after treatment for acute rejection. RESULTS There were 206 bronchoscopies, including 189 SBs and 17 CIBs, performed in 28 patients who underwent cadaveric lung transplantation between 2000 and 2013 at Osaka University Hospital. Among SBs, 92 (49%) showed positive results of transbronchial lung biopsy (TBLB) or bronchoalveolar lavage (BAL), and intervention was applied following 34 SBs (18%). Among CIBs, 8 (47%) showed positive results of TBLB or BAL, with intervention performed in 3 patients (18%). A2-3 and B2R findings according to the revised International Society for Heart and Lung Transplantation (ISHLT) rejection score and airway infection/colonization were frequently observed within a year following lung transplantation. Cytomegalovirus infection was found in 7 SBs (6%) by TBLB only within 2 months after transplantation. Regarding complications, moderate bleeding occurred in 21 (11%), pneumothorax in 2 (1%), prolonged hypoxemia in 1 (0.5%), and pneumonia in 1 (0.5%) among the 189 SBs. CONCLUSION SB frequently detects rejection and airway infection or colonization with minimum complications, especially within 12 months after cadaveric lung transplantation.
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Affiliation(s)
- M Inoue
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - M Minami
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - N Wada
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - T Nakagiri
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - S Funaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - T Kawamura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Y Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - M Okumura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Neujahr DC. Assessing the cells in the lung lavage: an untapped resource in lung transplant monitoring. Am J Transplant 2014; 14:748-9. [PMID: 24447821 DOI: 10.1111/ajt.12632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/11/2013] [Accepted: 12/11/2013] [Indexed: 01/25/2023]
Affiliation(s)
- D C Neujahr
- Emory University Transplant Center, Emory University School of Medicine, Atlanta, GA
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Laporta Hernández R, Lázaro Carrasco MT, Varela de Ugarte A, Ussetti Gil P. Seguimiento a largo plazo del paciente trasplantado pulmonar. Arch Bronconeumol 2014; 50:67-72. [DOI: 10.1016/j.arbres.2013.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 10/25/2022]
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Yserbyt J, Dooms C, Decramer M, Verleden GM. Acute lung allograft rejection: diagnostic role of probe-based confocal laser endomicroscopy of the respiratory tract. J Heart Lung Transplant 2014; 33:492-8. [PMID: 24656287 DOI: 10.1016/j.healun.2014.01.857] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 12/27/2013] [Accepted: 01/17/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Acute cellular rejection (AR) after lung transplantation may result in significant morbidity and mortality both on the short and long term. Transbronchial biopsy through flexible bronchoscopy is highly sensitive for the diagnosis of AR, but reproducibility of histopathologic interpretation is less convincing. Probe-based confocal laser endomicroscopy (pCLE), a novel imaging tool in the field of respiratory medicine, enables real-time imaging of the pulmonary acini. METHODS We performed 105 bronchoscopies in lung transplant recipients, combining both transbronchial biopsies and pCLE. We conducted an observational survey for pCLE findings in AR. RESULTS Calculations for cellularity showed a median cell count (ACA) of 50 (IQR 18 to 120) cells per microscopic field for AR and 10 (IQR 0 to 15) cells per microscopic field for matched controls (p = 0.0004). Cellular autofluorescence in the AR group was 1,163 (± 157) units and 489 (± 101) units for the matched controls (p = 0.0009). Autofluorescent cells were present in 73% (± 10) of the recorded frames in the AR group and in only 42% (± 9) of the recorded frames in the control group (p = 0.03). Contingency analysis for the presence/absence of ACA in the AR group versus the control group showed a sensitivity of 0.93 and a specificity of 0.46 (relative risk = 6.5 [95% CI 0.94 to 44.8], p = 0.01). The consecutive application of 3 pCLE criteria resulted in a sensitivity of 0.93 and a specificity of 0.83 for detection of AR. CONCLUSION Our observational survey suggests the existence of specific pCLE characteristics in patients with AR. Further efforts are necessary to validate these findings prospectively.
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Affiliation(s)
- Jonas Yserbyt
- Respiratory Division, University Hospitals Leuven; Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Christophe Dooms
- Respiratory Division, University Hospitals Leuven; Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marc Decramer
- Respiratory Division, University Hospitals Leuven; Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Geert M Verleden
- Respiratory Division, University Hospitals Leuven; Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Wong JY. Surveillance transbronchial biopsies in infant lung and heart-lung transplant recipients: practice, safety and value. Pediatr Transplant 2013; 17:592-4. [PMID: 24033919 DOI: 10.1111/petr.12139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jackson Y Wong
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
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Weigt SS, DerHovanessian A, Wallace WD, Lynch JP, Belperio JA. Bronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation. Semin Respir Crit Care Med 2013; 34:336-51. [PMID: 23821508 PMCID: PMC4768744 DOI: 10.1055/s-0033-1348467] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. Clinically, BOS manifests as airway obstruction and dyspnea that are classically progressive and ultimately fatal; however, the course is highly variable, and distinguishable phenotypes may exist. There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.
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Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
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Fruchter O, Fridel L, Rosengarten D, Raviv Y, Rosanov V, Kramer MR. Transbronchial cryo-biopsy in lung transplantation patients: First report. Respirology 2013; 18:669-73. [DOI: 10.1111/resp.12037] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/06/2012] [Accepted: 11/10/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - Ludmila Fridel
- Department of Pathology; Rabin Medical Center; Petah Tiqwa; Israel
| | | | - Yael Raviv
- Pulmonary Institute; Rabin Medical Center; Petah Tiqwa; Israel
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Greenland JR, Jones KD, Hays SR, Golden JA, Urisman A, Jewell NP, Caughey GH, Trivedi NN. Association of large-airway lymphocytic bronchitis with bronchiolitis obliterans syndrome. Am J Respir Crit Care Med 2012; 187:417-23. [PMID: 23239157 DOI: 10.1164/rccm.201206-1025oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Lung transplantation offers great promise for otherwise terminal lung diseases, but the development of bronchiolitis obliterans syndrome (BOS) continues to limit survival. Although acute rejection and lymphocytic bronchiolitis have been identified as risk factors for the development of BOS, it is unclear whether large-airway lymphocytic inflammation conveys the same risk. OBJECTIVES We evaluated lymphocytic bronchitis on endobronchial biopsies as a risk factor for BOS and mortality. METHODS Endobronchial biopsies were collected and graded during surveillance after lung transplantation. We assessed samples with negative cultures collected in the first 90 days from 298 subjects and compared large-airway lymphocytic bronchitis assessed by a 0-2 "E-score" and with standard A and BR pathology scores for acute rejection and small-airway lymphocytic bronchiolitis, respectively. MEASUREMENTS AND MAIN RESULTS We found surprisingly little association between large- and small-airway lymphocytic inflammation scores from a given bronchoscopy. Endobronchial lymphocytic bronchitis was more prevalent in subjects in BOS stage 0p and BOS stages 1-3 at the time of biopsy. Within 90 days after transplantation, increasing maximum E-score was associated with greater risk of BOS (adjusted hazard ratio, 1.76; 95% confidence interval, 1.11-2.78; P = 0.02) and in this analysis 90-day maximum E-scores were the only score type predictive of BOS (P < 0.01). CONCLUSIONS These results support a multicenter study to evaluate endoscopic biopsies for the identification of patients at increased risk for BOS. The association of endobronchial lymphocytic inflammation and BOS may have mechanistic implications.
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Affiliation(s)
- John R Greenland
- Department of Medicine, University of California at San Francisco, San Francisco, CA 94121, USA
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Cumulative exposure to CD8+ granzyme Bhi T cells is associated with reduced lung function early after lung transplantation. Transplant Proc 2012; 43:3892-8. [PMID: 22172867 DOI: 10.1016/j.transproceed.2011.09.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/16/2011] [Indexed: 11/20/2022]
Abstract
Outcomes following lung transplant remain suboptimal. This is attributable to variable posttransplant recovery of lung function, and inconsistent degrees of lung function loss after peak function is reached. Granzyme B is elevated in the blood and bronchoalveolar lavage (BAL) in acute rejection. We hypothesized that persistent exposure to T cells high in granzyme B would negatively correlate with lung function. We investigated cumulative exposure measured as the area-under-the-curve (AUC) of CD8+ T cell granzyme Bhi cells in the first year posttransplant in both BAL and blood in 24 transplant recipients. We assessed the correlation between cumulative 1-year exposure and FEV1 slope. There was a negative correlation between 1-year exposure and FEV1 slope within the first year (r=-0.63; P=.001). This relationship persisted even when adjusted for transplant type, gender, age, rejection, and indication for transplantation. In contrast, no relationship was seen with the 1-year AUC and lung function after 1 year posttransplant. In contrast to the BAL granzyme Bhi levels, granzyme Bhi levels from the blood showed no relationship with lung function. These findings suggest that CD8+ T-cell-driven factors are responsible for early improvements in lung function after transplantation.
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Davis WA, Finlen Copeland CA, Todd JL, Snyder LD, Martissa JA, Palmer SM. Spirometrically significant acute rejection increases the risk for BOS and death after lung transplantation. Am J Transplant 2012; 12:745-52. [PMID: 22123337 PMCID: PMC3753790 DOI: 10.1111/j.1600-6143.2011.03849.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute rejection (AR) is a common complication following lung transplantation and is an established risk factor for bronchiolitis obliterans syndrome (BOS). AR clinical presentation varies considerably and is sometimes associated with an acute decrease in forced expiratory volume in 1 s (FEV1). We hypothesized that lung transplant recipients who experience such spirometrically significant AR (SSAR), as defined by a ≥10% decline in FEV1 relative to the prior pulmonary function test, are subsequently at increased risk for BOS and worse overall survival. In a large single center cohort (n = 339), SSAR occurred in 79 subjects (23%) and significantly increased the risk for BOS (p < 0.0001, HR = 3.2, 95% CI 2.3-4.6) and death (p = 0.0001, HR = 2.3, 95% CI 1.5-3.5). These effects persisted after multivariate adjustment for pre-BOS AR and lymphocytic bronchiolitis burden. An analysis of the subset of patients who experienced severe SSAR (≥20% decline in FEV1) resulted in even greater hazards for BOS and death. Thus, we demonstrate a novel physiological measure that allows discrimination of patients at increased risk for worse posttransplant outcomes. Further studies are needed to determine mechanisms of airflow impairment and whether aggressive clinical interventions could improve post-SSAR outcomes.
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Affiliation(s)
- WA Davis
- Department of Medicine, Duke University, Durham NC
| | | | - JL Todd
- Department of Medicine, Duke University, Durham NC
| | - LD Snyder
- Department of Medicine, Duke University, Durham NC
| | - JA Martissa
- Department of Medicine, Duke University, Durham NC
| | - SM Palmer
- Department of Medicine, Duke University, Durham NC
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Smith L, Singer JP, Hayes M, Golden JA, Leard LE. An analysis of potential risk factors for early complications from fiberoptic bronchoscopy in lung transplant recipients. Transpl Int 2011; 25:172-8. [PMID: 22151411 DOI: 10.1111/j.1432-2277.2011.01392.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Several reviews exist describing the safety of bronchoscopy in lung transplant recipients. However, the incidence of bronchoscopic complications in lung transplant recipients in relation to trainee involvement, and clinical characteristics such as pre-transplant diagnosis and transplant type, has not been described. We performed a retrospective cohort study of all lung transplant recipients undergoing flexible fiberoptic bronchoscopy (n = 259) at the University of California, San Francisco, between January, 2003, and June, 2009. Complications included bleeding, pneumothorax, aspiration, oversedation, and hypoxemia. From 2003 to 2009, 3734 flexible fiberoptic bronchoscopies were performed, including 2111 (57%) with transbronchial biopsies. Trainees were involved in 2102 bronchoscopies (56%), including 1046 transbronchial biopsies (49.5%). Complications occurred in 27 bronchoscopies [0.7% (95% Confidence Interval [CI]: 0.4-1.0)], with 10 involving a trainee (37%). Twenty (74%) occurred during bronchoscopies with transbronchial biopsies. Six of these involved a trainee, while 14 involved an attending alone (P = 0.03). We did not find differences in pre-transplant diagnosis, transplant type, lung, or renal function between subjects who suffered a complication and those who did not (P ≥ 0.30). The involvement of trainees, pre-transplant diagnosis, and transplant type do not significantly impact the rate of bronchoscopic complications in lung transplant recipients.
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Affiliation(s)
- Leah Smith
- Department of Medicine, Division of Pulmonary and Critical Care, University of California, San Francisco, CA 94143-0903, USA.
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Benden C, Faro A, Worley S, Arrigain S, Aurora P, Ballmann M, Boyer D, Conrad C, Eichler I, Elidemir O, Goldfarb S, Mallory GB, Mogayzel PJ, Parakininkas D, Solomon M, Visner G, Sweet SC, Danziger-Isakov LA. Minimal acute rejection in pediatric lung transplantation--does it matter? Pediatr Transplant 2010; 14:534-9. [PMID: 20059725 PMCID: PMC2888626 DOI: 10.1111/j.1399-3046.2009.01268.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In adult lung transplantation, a single minimal AR episode is a significant predictor of BOS independent of other factors. However, the significance of single minimal AR episodes in children is unknown. A retrospective, multi-center analysis was performed to determine whether isolated single AR episodes are associated with an increased BOS risk in children. Risk factors for BOS, death, or re-transplantation, and a combined outcome of BOS, death, or re-transplantation were assessed. Original data included 577 patients (<21 yr of age). A total of 383 subjects were eligible for the study. Fifteen percent of patients developed BOS, and 13% of patients either died or underwent re-transplant within one-yr post-transplant. In the multivariable survival model for time to BOS, there was no significant risk to developing BOS after a single minimal AR (A1) episode (HR 1.7, 95% CI 0.64-4.8; p=0.28). Even after a second minimal AR episode, no significant risk for BOS was appreciated. However, a single episode of mild AR (A2) was associated with twice the risk of BOS within one-yr post-transplant. In this select cohort, a single minimal AR episode was not associated with an increased risk for BOS within one yr following lung transplantation, in contrast to previous reports in adults.
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Affiliation(s)
- Christian Benden
- Division of Pulmonary Medicine, University Hospital, Zurich, Switzerland.
| | - Albert Faro
- Washington University School of Medicine & St Louis Children’s Hospital, MO, USA
| | - Sarah Worley
- The Children’s Hospital at Cleveland Clinic, Cleveland, OH, USA
| | - Susana Arrigain
- The Children’s Hospital at Cleveland Clinic, Cleveland, OH, USA
| | - Paul Aurora
- Great Ormond Street Hospital for Children & Institute of Child Health, London, UK
| | | | - Debra Boyer
- Harvard University & Children’s Hospital Boston, MA, USA
| | - Carol Conrad
- Lucile Packard Children’s Hospital at Stanford University, Palo Alto, CA, USA
| | | | - Okan Elidemir
- Baylor College of Medicine & Texas Children’s Hospital, Houston, TX, USA
| | | | - George B Mallory
- Baylor College of Medicine & Texas Children’s Hospital, Houston, TX, USA
| | | | - Daiva Parakininkas
- Medical College of Wisconsin & Children’s Hospital Wisconsin, Milwaukee, WI, USA
| | | | - Gary Visner
- Harvard University & Children’s Hospital Boston, MA, USA
| | - Stuart C Sweet
- Washington University School of Medicine & St Louis Children’s Hospital, MO, USA
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The controversial role of surveillance bronchoscopy after lung transplantation. Curr Opin Organ Transplant 2010; 14:494-8. [PMID: 19620869 DOI: 10.1097/mot.0b013e3283300a3b] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Clinically mandated transbronchial biopsy is universally regarded as the most efficient tool to establish pathology in the allograft. However, the utility of surveillance transbronchial biopsy to facilitate early detection and treatment of acute pulmonary allograft rejection is a matter of current debate. The purpose of this review is to summarize the evidence for and against the performance of surveillance bronchoscopy postlung transplantation, to discuss the risk/benefit ratio and the application of this procedure in the individual patient. RECENT FINDINGS Detection of silent acute rejection of the pulmonary allograft remains an important benefit of surveillance bronchoscopy although definitive evidence for a positive impact on survival or prevention of development of the bronchiolitis syndrome (BOS) is yet to be demonstrated. Perhaps the wrong target has been the focus as new evidence suggests that high grade lymphocytic bronchiolitis is the important independent risk factor for the development of BOS and death after lung transplantation. Providing effective therapies for lymphocytic bronchiolitis can be developed there is now strong support for performance of surveillance transbronchial biopsy. Most studies attest to a low risk of severe complications. SUMMARY Surveillance bronchoscopy is useful to detect asymptomatic acute rejection but also to determine the presence and severity of lymphocytic bronchiolitis, which should be the new target of therapeutic endeavours. It is acknowledged that the true risk/benefit ratio of surveillance bronchoscopy may differ between programs so each case deserves individual consideration.
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Lung. PATHOLOGY OF SOLID ORGAN TRANSPLANTATION 2009. [PMCID: PMC7120462 DOI: 10.1007/978-3-540-79343-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Experiments with animals in the 1940 and 1950s demonstrated that lung transplantation was technically possible [33]. In 1963, Dr. James Hardy performed the first human lung transplantation. The recipient survived 18 days, ultimately succumbing to renal failure and malnutrition [58]. From 1963 through 1978, multiple attempts at lung transplantation failed because of rejection and complications at the bronchial anastomosis. In the 1980s, improvements in immunosuppression, especially the introduction of cyclosporin A, and enhanced surgical techniques led to renewed interest in organ transplantation. In 1981, a 45-year-old-woman received the first successful heart–lung transplantation for idiopathic pulmonary arterial hypertension (IPAH) [106]. She survived 5 years after the procedure. Two years later the first successful single lung transplantation for idiopathic pulmonary fibrosis (IPF) [128] was reported, and in 1986 the first double lung transplantation for emphysema [25] was performed.
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