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Iturbe-Fernández D, de Pablo Gafas A, Mora Cuesta VM, Alonso Moralejo R, Quezada Loaiza CA, Pérez González V, López-Padilla D, Cifrián JM. Everolimus Treatment for Chronic Lung Allograft Dysfunction in Lung Transplantation. Life (Basel) 2024; 14:603. [PMID: 38792624 PMCID: PMC11123303 DOI: 10.3390/life14050603] [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: 02/08/2024] [Revised: 03/20/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Our study aims to evaluate the effect of everolimus treatment on lung function in lung transplant (LT) patients with established chronic lung allograft dysfunction (CLAD). METHODS This retrospective study included LT patients in two reference LT units who started everolimus therapy to treat CLAD from October 2008 to October 2016. We assessed the variation in the maximum forced expiratory volume in the first second (FEV1) before and after the treatment. RESULTS Fifty-seven patients were included in this study. The variation in the FEV1 was -102.7 (149.6) mL/month before starting everolimus compared to -44.7 (109.6) mL/month within the first three months, +1.4 (63.5) mL/month until the sixth month, and -7.4 (46.2) mL/month until the twelfth month (p < 0.05). Glomerular filtrate remained unchanged after everolimus treatment [59.1 (17.5) mL/min per 1.73 m2 at baseline and 60.9 (19.6) mL/min per 1.73 m2, 57.7 (20.5) mL/min per 1.73 m2, and 57.3 (17.8) mL/min per 1.73 m2, at 1, 3, and 6 months, respectively] (p > 0.05). Everolimus was withdrawn in 22 (38.6%) patients. The median time to withdrawal was 14.1 (5.5-25.1) months. CONCLUSIONS This study showed an improvement in FEV1 decline in patients with CLAD treated with everolimus. However, the drug was withdrawn in a high proportion of patients.
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Affiliation(s)
- David Iturbe-Fernández
- Lung Transplant Unit, Pulmonary Medicine Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain; (V.M.M.C.); (J.M.C.)
| | - Alicia de Pablo Gafas
- Lung Transplant Unit, Pulmonary Medicine Department, Doce de Octubre University Hospital, 28041 Madrid, Spain; (A.d.P.G.); (R.A.M.); (C.A.Q.L.); (V.P.G.)
| | - Víctor Manuel Mora Cuesta
- Lung Transplant Unit, Pulmonary Medicine Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain; (V.M.M.C.); (J.M.C.)
| | - Rodrigo Alonso Moralejo
- Lung Transplant Unit, Pulmonary Medicine Department, Doce de Octubre University Hospital, 28041 Madrid, Spain; (A.d.P.G.); (R.A.M.); (C.A.Q.L.); (V.P.G.)
| | - Carlos Andrés Quezada Loaiza
- Lung Transplant Unit, Pulmonary Medicine Department, Doce de Octubre University Hospital, 28041 Madrid, Spain; (A.d.P.G.); (R.A.M.); (C.A.Q.L.); (V.P.G.)
- CIBER Respiratory Diseases (CIBERES), Carlos III Health Institute, 28029 Madrid, Spain
| | - Virginia Pérez González
- Lung Transplant Unit, Pulmonary Medicine Department, Doce de Octubre University Hospital, 28041 Madrid, Spain; (A.d.P.G.); (R.A.M.); (C.A.Q.L.); (V.P.G.)
| | - Daniel López-Padilla
- Pulmonary Medicine Department, Gregorio Marañón University Hospital, 28007 Madrid, Spain
| | - José M. Cifrián
- Lung Transplant Unit, Pulmonary Medicine Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain; (V.M.M.C.); (J.M.C.)
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Bos S, Pradère P, Beeckmans H, Zajacova A, Vanaudenaerde BM, Fisher AJ, Vos R. Lymphocyte Depleting and Modulating Therapies for Chronic Lung Allograft Dysfunction. Pharmacol Rev 2023; 75:1200-1217. [PMID: 37295951 PMCID: PMC10595020 DOI: 10.1124/pharmrev.123.000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/27/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023] Open
Abstract
Chronic lung rejection, also called chronic lung allograft dysfunction (CLAD), remains the major hurdle limiting long-term survival after lung transplantation, and limited therapeutic options are available to slow the progressive decline in lung function. Most interventions are only temporarily effective in stabilizing the loss of or modestly improving lung function, with disease progression resuming over time in the majority of patients. Therefore, identification of effective treatments that prevent the onset or halt progression of CLAD is urgently needed. As a key effector cell in its pathophysiology, lymphocytes have been considered a therapeutic target in CLAD. The aim of this review is to evaluate the use and efficacy of lymphocyte depleting and immunomodulating therapies in progressive CLAD beyond usual maintenance immunosuppressive strategies. Modalities used include anti-thymocyte globulin, alemtuzumab, methotrexate, cyclophosphamide, total lymphoid irradiation, and extracorporeal photopheresis, and to explore possible future strategies. When considering both efficacy and risk of side effects, extracorporeal photopheresis, anti-thymocyte globulin and total lymphoid irradiation appear to offer the best treatment options currently available for progressive CLAD patients. SIGNIFICANCE STATEMENT: Effective treatments to prevent the onset and progression of chronic lung rejection after lung transplantation are still a major shortcoming. Based on existing data to date, considering both efficacy and risk of side effects, extracorporeal photopheresis, anti-thymocyte globulin, and total lymphoid irradiation are currently the most viable second-line treatment options. However, it is important to note that interpretation of most results is hampered by the lack of randomized controlled trials.
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Affiliation(s)
- Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Pauline Pradère
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Hanne Beeckmans
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Andrea Zajacova
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Bart M Vanaudenaerde
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Robin Vos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
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Halitim P, Tissot A. [Chronic lung allograft dysfunction in 2022, past and updates]. Rev Mal Respir 2023; 40:324-334. [PMID: 36858879 DOI: 10.1016/j.rmr.2023.01.025] [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: 09/21/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION While short-term results of lung transplantation have improved considerably, long-term survival remains below that achieved for other solid organ transplants. CURRENT KNOWLEDGE The main cause of late mortality is chronic lung allograft dysfunction (CLAD), which affects nearly half of the recipients 5 years after transplantation. Immunological and non-immune risk factors have been identified. These factors activate the innate and adaptive immune system, leading to lesional and altered wound-healing processes, which result in fibrosis affecting the small airways or interstitial tissue. Several phenotypes of CLAD have been identified based on respiratory function and imaging pattern. Aside from retransplantation, which is possible for only small number of patients, no treatment can reverse the CLAD process. PERSPECTIVES Current therapeutic research is focused on anti-fibrotic treatments and photopheresis. Basic research has identified numerous biomarkers that could prove to be relevant as therapeutic targets. CONCLUSION While the pathophysiological mechanisms of CLAD are better understood than before, a major therapeutic challenge remains.
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Affiliation(s)
- P Halitim
- Service de pneumologie et soins intensifs, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France; Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France
| | - A Tissot
- Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France.
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Patterson CM, Jolly EC, Burrows F, Ronan NJ, Lyster H. Conventional and Novel Approaches to Immunosuppression in Lung Transplantation. Clin Chest Med 2023; 44:121-136. [PMID: 36774159 DOI: 10.1016/j.ccm.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Most therapeutic advances in immunosuppression have occurred over the past few decades. Although modern strategies have been effective in reducing acute cellular rejection, excess immunosuppression comes at the price of toxicity, opportunistic infection, and malignancy. As our understanding of the immune system and allograft rejection becomes more nuanced, there is an opportunity to evolve immunosuppression protocols to optimize longer term outcomes while mitigating the deleterious effects of traditional protocols.
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Affiliation(s)
- Caroline M Patterson
- Transplant Continuing Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Elaine C Jolly
- Division of Renal Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Fay Burrows
- Department of Pharmacy, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Nicola J Ronan
- Transplant Continuing Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Haifa Lyster
- Cardiothoracic Transplant Unit, Royal Brompton and Harefield Hospitals, Part of Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom; Kings College, London, United Kingdom; Pharmacy Department, Royal Brompton and Harefield Hospitals, Part of Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
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Glanville AR, Benden C, Bergeron A, Cheng GS, Gottlieb J, Lease ED, Perch M, Todd JL, Williams KM, Verleden GM. Bronchiolitis obliterans syndrome after lung or haematopoietic stem cell transplantation: current management and future directions. ERJ Open Res 2022; 8:00185-2022. [PMID: 35898810 PMCID: PMC9309343 DOI: 10.1183/23120541.00185-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) may develop after either lung or haematopoietic stem cell transplantation (HSCT), with similarities in histopathological features and clinical manifestations. However, there are differences in the contributory factors and clinical trajectories between the two conditions. BOS after HSCT occurs due to systemic graft-versus-host-disease (GVHD), whereas BOS after lung transplantation is limited to the lung allograft. BOS diagnosis after HSCT is more challenging, as the lung function decline may occur due to extrapulmonary GVHD, causing sclerosis or inflammation in the fascia or muscles of the respiratory girdle. Treatment is generally empirical with no established effective therapies. This review provides rare insights and commonalities of both conditions, that are not well elaborated elsewhere in contemporary literature, and highlights the importance of cross disciplinary learning from experts in other transplant modalities. Treatment algorithms for each condition are presented, based on the published literature and consensus clinical opinion. Immunosuppression should be optimised, and other conditions or contributory factors treated where possible. When initial treatment fails, the ultimate therapeutic option is lung transplantation (or re-transplantation in the case of BOS after lung transplantation) in carefully selected candidates. Novel therapies under investigation include aerosolised liposomal cyclosporine, Janus kinase inhibitors, antifibrotic therapies, and (in patients with BOS after lung transplantation) B-cell–directed therapies. Effective novel treatments that have a tangible impact on survival and thereby avoid the need for lung transplantation or re-transplantation are urgently required.
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Venado A, Kukreja J, Greenland JR. Chronic Lung Allograft Dysfunction. Thorac Surg Clin 2022; 32:231-242. [PMID: 35512941 DOI: 10.1016/j.thorsurg.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) is a syndrome of progressive lung function decline, subcategorized into obstructive, restrictive, and mixed phenotypes. The trajectory of CLAD is variable depending on the phenotype, with restrictive and mixed phenotypes having more rapid progression and lower survival. The mechanisms driving CLAD development remain unclear, though allograft injury during primary graft dysfunction, acute cellular rejection, antibody-mediated rejection, and infections trigger immune responses with long-lasting effects that can lead to CLAD months or years later. Currently, retransplantation is the only effective treatment.
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Affiliation(s)
- Aida Venado
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, 505 Parnassus Ave, M1093A, San Francisco, CA 94143-2204, USA.
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Univeristy of California, San Francisco, 500 Parnassus Ave, MU 405W Suite 305, San Francisco, CA 94143, USA
| | - John R Greenland
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, SF VAHCS Building 2, Room 453 (Mail stop 111D), 4150 Clement St, San Francisco CA 94121, USA
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7
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Pulmonary graft-versus-host disease and chronic lung allograft dysfunction: two sides of the same coin? THE LANCET RESPIRATORY MEDICINE 2022; 10:796-810. [DOI: 10.1016/s2213-2600(22)00001-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/17/2021] [Accepted: 01/04/2022] [Indexed: 11/23/2022]
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Bedair B, Hachem RR. Management of chronic rejection after lung transplantation. J Thorac Dis 2022; 13:6645-6653. [PMID: 34992842 PMCID: PMC8662511 DOI: 10.21037/jtd-2021-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/20/2021] [Indexed: 12/17/2022]
Abstract
Outcomes after lung transplantation are limited by chronic lung allograft dysfunction (CLAD). The incidence of CLAD is high, and its clinical course tends to be progressive over time, culminating in graft failure and death. Indeed, CLAD is the leading cause of death beyond the first year after lung transplantation. Therapy for CLAD has been limited by a lack of high-quality studies to guide management. In this review, we will discuss the diagnosis of CLAD in light of the recent changes to definitions and will discuss the current clinical evidence available for treatment. Recently, the diagnosis of CLAD has been subdivided into bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). The current evidence for treatment of CLAD mainly revolves around treatment of BOS with more limited data existing for RAS. The best supported treatment to date for CLAD is the macrolide antibiotic azithromycin which has been associated with a small improvement in lung function in a minority of patients. Other therapies that have more limited data include switching immunosuppression from cyclosporine to tacrolimus, fundoplication for gastroesophageal reflux, montelukast, extracorporeal photopheresis (ECP), aerosolized cyclosporine, cytolytic anti-lymphocyte therapies, total lymphoid irradiation (TLI) and the antifibrotic agent pirfenidone. Most of these treatments are supported by case series and observational studies. Finally, we will discuss the role of retransplantation for CLAD.
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Affiliation(s)
- Bahaa Bedair
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, MO 63110, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, MO 63110, USA
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9
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Chronic lung allograft dysfunction. Indian J Thorac Cardiovasc Surg 2021; 38:318-325. [DOI: 10.1007/s12055-021-01228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/11/2021] [Accepted: 06/21/2021] [Indexed: 10/19/2022] Open
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Arjuna A, Olson MT, Walia R, Bremner RM, Smith MA, Mohanakumar T. An update on current treatment strategies for managing bronchiolitis obliterans syndrome after lung transplantation. Expert Rev Respir Med 2020; 15:339-350. [PMID: 33054424 DOI: 10.1080/17476348.2021.1835475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Bronchiolitis obliterans syndrome (BOS), a subtype of chronic lung allograft dysfunction, is quite common, with up to half of all lung recipients developing BOS within 5 years of transplantation. Preventive efforts are aimed at alleviating known risk factors of BOS development, while the primary goal of treatment is to delay the irreversible, fibrotic airway changes, and progressive loss of lung function. AREAS COVERED This narrative review will briefly discuss the updated definition, clinical presentation, pathogenesis, risk factors, and survival after BOS while paying particular attention to the salient evidence for optimal preventive strategies and treatments based on investigations in the modern era. EXPERT OPINION Future translational research focused on further characterizing the complex interplay between immune and nonimmune mechanisms mediating chronic lung rejection is the first step toward mitigating risk of allograft injury, improving early disease detection with noninvasive biomarkers, and ultimately, developing an effective, targeted therapy that can extend the life of the lung allograft.
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Affiliation(s)
- Ashwini Arjuna
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael T Olson
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA.,Phoenix Campus, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Rajat Walia
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Ross M Bremner
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael A Smith
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
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Davidson JR, Franklin D, Kumar S, Mohammadi B, Dawas K, Eaton S, Curry J, De Coppi P, Abbassi-Ghadi N. Fundoplication to preserve allograft function after lung transplant: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:858-866. [DOI: 10.1016/j.jtcvs.2019.10.185] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/08/2019] [Accepted: 10/25/2019] [Indexed: 12/29/2022]
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12
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Modulation of NLRP3 Inflammasome through Formyl Peptide Receptor 1 (Fpr-1) Pathway as a New Therapeutic Target in Bronchiolitis Obliterans Syndrome. Int J Mol Sci 2020; 21:ijms21062144. [PMID: 32244997 PMCID: PMC7139667 DOI: 10.3390/ijms21062144] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/14/2020] [Accepted: 03/19/2020] [Indexed: 01/12/2023] Open
Abstract
Chronic rejection is the major leading cause of morbidity and mortality after lung transplantation. Bronchiolitis obliterans syndrome (BOS), a fibroproliferative disorder of the small airways, is the main manifestation of chronic lung allograft rejection. We investigated, using transgenic mice, the mechanisms through which the deficiency of IL-1β/IL-18, Casp-1, or Fpr-1 genes could be protective in an experimental model of BOS, induced in mice by allogeneic heterotopic tracheal transplantation. Fpr-1 KO mice showed a marked reduction in histological markers of BOS and of mast cell numbers compared to other groups. Molecular analyses indicated that the absence of the Fpr-1 gene was able to decrease NF-κB nuclear translocation and modulate NLRP3 inflammasome signaling and the mitogen-activated protein kinase (MAPK) pathway in a more significant way compared to other groups. Additionally, Fpr-1 gene deletion caused a reduction in resistance to the apoptosis, assessed by the TUNEL assay. Immunohistochemical analyses indicated changes in nitrotyrosine, PARP, VEGF, and TGF-β expression associated with the pathology, which were reduced in the absence of the Fpr1 gene more so than by the deletion of IL-1β/IL-18 and Casp-1. We underline the importance of the NLRP3 inflammasome and the pathogenic role of Fpr-1 in experimental models of BOS, which is the result of the modulation of immune cell recruitment together with the modulation of local cellular activation, suggesting this gene as a new target in the control of the pathologic features of BOS.
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13
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Postinfectious Bronchiolitis Obliterans in Children: Diagnostic Workup and Therapeutic Options: A Workshop Report. Can Respir J 2020; 2020:5852827. [PMID: 32076469 PMCID: PMC7013295 DOI: 10.1155/2020/5852827] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/29/2019] [Accepted: 12/27/2019] [Indexed: 12/23/2022] Open
Abstract
Bronchiolitis obliterans (BO) is a rare, chronic form of obstructive lung disease, often initiated with injury of the bronchiolar epithelium followed by an inflammatory response and progressive fibrosis of small airways resulting in nonuniform luminal obliteration or narrowing. The term BO comprises a group of diseases with different underlying etiologies, courses, and characteristics. Among the better recognized inciting stimuli leading to BO are airway pathogens such as adenovirus and mycoplasma, which, in a small percentage of infected children, will result in progressive fixed airflow obstruction, an entity referred to as postinfectious bronchiolitis obliterans (PIBO). The present knowledge on BO in general is reasonably well developed, in part because of the relatively high incidence in patients who have undergone lung transplantation or bone marrow transplant recipients who have had graft-versus-host disease in the posttransplant period. The cellular and molecular pathways involved in PIBO, while assumed to be similar, have not been adequately elucidated. Since 2016, an international consortium of experts with an interest in PIBO assembles on a regular basis in Geisenheim, Germany, to discuss key areas in PIBO which include diagnostic workup, treatment strategies, and research fields.
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Lebeer M, Kaes J, Lambrech M, Vanstapel A, Beeckmans H, Ambrocio GP, Vanaudenaerde BM, Verleden SE, Verbeken EK, Neyrinck AP, Ceulemans LJ, Van Raemdonck DE, Verleden GM, Vos R, Godinas L, Yserbyt J, Dupont LJ, Van Herck A, Sacreas A, Heigl T, Ordies S, Schaevers V, De Leyn P, Coosemans W, Nafteux P, Decaluwé H, Van Veer H, Depypere L, Frick AE, Weynand B, Emonds M, Lievens Y. Total lymphoid irradiation in progressive bronchiolitis obliterans syndrome after lung transplantation: a single‐center experience and review of literature. Transpl Int 2019; 33:216-228. [DOI: 10.1111/tri.13544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/03/2019] [Accepted: 10/18/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Marnix Lebeer
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
| | - Janne Kaes
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Maarten Lambrech
- Department of Radiation Oncology University Hospitals Leuven Leuven Belgium
| | - Arno Vanstapel
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Hanne Beeckmans
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
| | - Gene P.L. Ambrocio
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
| | - Bart M. Vanaudenaerde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Stijn E. Verleden
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | | | - Arne P. Neyrinck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
- Department of Anesthesiology University Hospitals Leuven Leuven Belgium
| | - Laurens J. Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
- Department of Thoracic Surgery University Hospitals Leuven Leuven Belgium
| | - Dirk E. Van Raemdonck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
- Department of Thoracic Surgery University Hospitals Leuven Leuven Belgium
| | - Geert M. Verleden
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Robin Vos
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
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15
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Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. Its history starts in the 1940s, initially hampered by early deaths due to perioperative problems and acute rejection. Improvement of surgical techniques and the introduction of immunosuppressive drugs resulted in longer survival. Chronic lung allograft dysfunction (CLAD), a new complication appeared and remains the most serious complication today. CLAD, the main reason why survival after lung transplantation is impaired compared to other solid-organ transplantations is characterized by a gradually increasing shortness of breath, reflected in a deterioration of pulmonary function status, respiratory insufficiency and possibly death.
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16
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Editorial: Current opinion in organ transplantation: lung transplantation. Curr Opin Organ Transplant 2019; 24:286-287. [DOI: 10.1097/mot.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Vos R, Eynde RV, Ruttens D, Verleden SE, Vanaudenaerde BM, Dupont LJ, Yserbyt J, Verbeken EK, Neyrinck AP, Van Raemdonck DE, Verleden GM. Montelukast in chronic lung allograft dysfunction after lung transplantation. J Heart Lung Transplant 2019; 38:516-527. [DOI: 10.1016/j.healun.2018.11.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 12/11/2022] Open
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18
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Diagnosis, Pathophysiology and Experimental Models of Chronic Lung Allograft Rejection. Transplantation 2019; 102:1459-1466. [PMID: 29683998 DOI: 10.1097/tp.0000000000002250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic rejection is the Achilles heel of modern lung transplantation, characterized by a slow, progressive decline in allograft function. Clinically, this manifests as obstructive disease, restrictive disease, or a mixture of the 2 depending on the underlying pathology. The 2 major phenotypes of chronic rejection include bronchiolitis obliterans syndrome and restrictive allograft syndrome. The last decade of research has revealed that each of these phenotypes has a unique underlying pathophysiology which may require a distinct treatment regimen for optimal control. Insights into the intricate alloimmune pathways contributing to chronic rejection have been gained from both large and small animal models, suggesting directions for future research. In this review, we explore the pathological hallmarks of chronic rejection, recent insights gained from both clinical and basic science research, and the current state of animal models of chronic lung rejection.
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19
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Chronic lung allograft dysfunction: Definition, diagnostic criteria, and approaches to treatment-A consensus report from the Pulmonary Council of the ISHLT. J Heart Lung Transplant 2019; 38:493-503. [PMID: 30962148 DOI: 10.1016/j.healun.2019.03.009] [Citation(s) in RCA: 476] [Impact Index Per Article: 95.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023] Open
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20
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Abstract
INTRODUCTION Bronchiolitis obliterans (BO) is a chronic and irreversible obstructive lung disease leading to the obstruction and/or obliteration of the small airways. Three main BO entities are distinguished: post-infectious BO (PIBO); BO post lung transplantation; and BO after bone marrow transplantation (BMT) or hematopoietic stem cell transplantation (HSCT). All three entities are separate, however, there are similarities in histopathological characteristics and possibly in aspects of the development pathway. Areas covered: We review current evidence of bronchiolitis obliterans diagnosis and management in children. The diagnosis of BO is usually based on a combination of history, clinical and radiological findings, although lung biopsy and histopathology remain the gold standard approaches to confirm BO. Expert opinion: At present, we do not have a clear understanding of the mechanisms of the development of BO and lack strong evidence for treatment. Although most BO in children is post-infectious, most of the current evidence for treatment originates from studies analyzing BO in adult lung transplant and HSCT patients. BO management requires multidisciplinary approach and care in specialized centers.
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Affiliation(s)
- Ema Kavaliunaite
- a Respiratory Unit , Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Paul Aurora
- a Respiratory Unit , Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK.,b Respiratory Critical Care and Anaesthesia Section , Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health , London , UK
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21
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Extracorporeal Photopheresis for Bronchiolitis Obliterans Syndrome After Lung Transplantation. Transplantation 2019; 102:1059-1065. [PMID: 29557913 DOI: 10.1097/tp.0000000000002168] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lung transplantation is a therapeutic option for select patients with end-stage lung disease. However, successful lung transplantation is hampered by chronic lung allograft dysfunction, in particular bronchiolitis obliterans syndrome (BOS). Although there is no approved or standard treatment for BOS, which may have several distinct phenotypes, extracorporeal photopheresis (ECP) has shown promising results in patients who develop BOS refractory to azithromycin treatment. METHODS We reviewed all relevant clinical data indexed on PubMed from 1987 to 2017 to evaluate the role of ECP in patients with BOS. RESULTS Seven small studies investigated the immunomodulatory effects of ECP in patients after solid organ transplant, and 12 studies reported clinical data specific to ECP therapy for BOS. Studies indicate that ECP triggers an apoptotic cellular cascade that exerts various immunomodulatory effects mediated via increases in anti-inflammatory cytokines, a decrease in proinflammatory cytokines, and an increase in tolerogenic regulatory T cells. Clinical evidence derived from relatively small single-center studies suggests that ECP therapy is associated with improvement or stabilization in lung function and sustainable, statistically significant, decreases in the rate of lung function decline in patients with BOS. Additionally, when adverse event data were reported, ECP was generally well tolerated. None of the comparative studies were randomized. CONCLUSIONS Immunomodulation mediated via ECP is a rational therapeutic option that may improve clinical outcomes in patients with BOS, particularly in the context of in-depth patient phenotyping as part of a stratified approach to treatment; good quality randomized controlled trials are needed to confirm observational findings.
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22
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Glanville AR. Montelukast for chronic lung allograft dysfunction: Not quite the "Full Monty". J Heart Lung Transplant 2019; 38:528-529. [PMID: 30765304 DOI: 10.1016/j.healun.2019.01.1312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Allan R Glanville
- Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia.
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23
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Abstract
Lung transplantation provides a realistic hope of improved survival and enhanced quality of life. However, outcomes can be disappointing, meaning many decisions are highly controversial. Practice is largely based on expert opinion and there is a dearth of high-level evidence. Not surprisingly, this leads to centre-specific practices that may vary considerably in controversial areas. The aim of this review, therefore, is to explore some of those domains and present the available evidence. As the science of lung transplantation approaches its fifth decade, we are only now reaching a critical mass of clinicians and scientific researchers to enable adequately powered studies to assist in informing our approach to some of these controversies. Lung transplantation provides a realistic hope of improved survival and enhanced quality of life. However, outcomes can be disappointing, meaning many decisions are highly controversial. Better evidence is desperately needed.http://ow.ly/Dl4N30maYV9
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Affiliation(s)
- David Abelson
- The Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
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24
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Parker WF, Bag R. Chronic Lung Allograft Dysfunction. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0208-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Siddiqui AS, Kumar G, Majumdar T, Graviss EA, Nguyen DT, Goodarzi A, Kaleekal T. Association of methacholine challenge test with diagnosis of chronic lung allograft dysfunction in lung transplant patients. Clin Transplant 2018; 32:e13397. [PMID: 30192029 DOI: 10.1111/ctr.13397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 08/08/2018] [Accepted: 08/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is a complication of lung transplantation. We sought to determine whether bronchial hyperresponsiveness detected by the methacholine challenge test (MCT) at 3 months after lung transplant (LT) predicts the development of CLAD. METHODS We performed a retrospective cohort study of 140 LT patients between 1/2008 and 6/2014 who underwent MCT at 3 months after LT. Pearson's chi-squared test and Kruskal-Wallis test were used to compare categorical and continuous variables, respectively. Cox proportional hazards modeling was used to evaluate the association between CLAD and MCT. RESULTS Methacholine challenge test+ was associated with the development of overall CLAD (adjusted hazards ratio [aHR]: 3.47; 95% confidence interval [95% CI]: 1.71, 7.03; P = 0.001) and CLAD within 3 years (aHR: 4.98; 95%CI: 1.84, 13.48; P = 0.002). Subgroup analysis showed that MCT (+) is associated with overall CLAD in single lung transplant (SLT) (aHR: 8.18; 95% CI: 2.22, 30.09; P = 0.002), double lung transplant (DLT) (aHR: 3.27; 95% CI: 1.22, 8.78; P = 0.02) and CLAD within 3 years in DLT patients (aHR: 6.76; 95% CI: 1.71, 26.74; P = 0.01). CONCLUSION Methacholine challenge test+ at 3 months after LT is associated with the development of overall CLAD. Positive MCT could predict the development of early CLAD within 3 years in DLT patients.
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Affiliation(s)
- Atif S Siddiqui
- Pulmonary and Critical Care, Houston Methodist Hospital, Houston, Texas
| | - Gagan Kumar
- Pulmonary and Critical Care, Northeast Georgia Medical Center, Gainesville, Georgia
| | | | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Ahmad Goodarzi
- Pulmonary Transplant, Houston Methodist Hospital, Houston, Texas
| | - Thomas Kaleekal
- Pulmonary Transplant, Houston Methodist Hospital, Houston, Texas
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26
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27
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Montelukast for bronchiolitis obliterans syndrome after lung transplantation: A randomized controlled trial. PLoS One 2018; 13:e0193564. [PMID: 29624575 PMCID: PMC5889063 DOI: 10.1371/journal.pone.0193564] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 02/06/2018] [Indexed: 12/03/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) remains the major problem which precludes long-term survival after lung transplantation. Previously, an open label pilot study from our group demonstrated a possible beneficial effect of montelukast in progressive BOS patients with low airway neutrophilia (<15%), and already on azithromycin treatment, in whom the further decline in pulmonary function was attenuated. This was, however, a non-randomized and non-placebo controlled trial. The study design is a single center, prospective, interventional, randomized, double blind, placebo-controlled trial, with a two arm parallel group design and an allocation ratio of 1:1. Randomization to additional montelukast (10 mg/day, n = 15) or placebo (n = 15) was performed from 2010 to 2014 at the University Hospitals Leuven (Leuven, Belgium) in all consecutive patients with late-onset (>2years posttransplant) BOS ≥1. Primary end-point was freedom from graft loss 1 year after randomization; secondary end-points were acute rejection, lymphocytic bronchiolitis, respiratory infection rate; and change in FEV1, airway and systemic inflammation during the study period. Graft loss at 1 y and 2y was similar in both groups (respectively p = 0. 981 and p = 0.230). Montelukast had no effect on lung function decline in the overall cohort. However, in a post-hoc subanalysis of BOS stage 1 patients, montelukast attenuated further decline of FEV1 during the study period, both in absolute (L) (p = 0.008) and % predicted value (p = 0.0180). A linear mixed model confirmed this association. Acute rejection, lymphocytic bronchiolitis, respiratory infections, systemic and airway inflammation were comparable between groups over the study period. This randomized controlled trial showed no additional survival benefit with montelukast compared to placebo, although the study was underpowered. The administration of montelukast was associated with an attenuation of the rate of FEV1 decline, however, only in recipients with late-onset BOS stage 1.
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28
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Pecoraro Y, Carillo C, Diso D, Mantovani S, Cimino G, De Giacomo T, Troiani P, Shafii M, Gherzi L, Amore D, Rendina EA, Venuta F, Anile M. Efficacy of Extracorporeal Photopheresis in Patients With Bronchiolitis Obliterans Syndrome After Lung Transplantation. Transplant Proc 2017; 49:695-698. [PMID: 28457374 DOI: 10.1016/j.transproceed.2017.02.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lung transplantation (LT) is only therapeutic option for patients affected by chronic respiratory failure. Chronic rejection, also known as bronchiolitis obliterans syndrome (BOS), is still the main cause of death and the most important factor that influences post-transplantation quality of life. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Extracorporeal photopheresis (ECP) seems to reduce the rate of lung function decline in transplant recipients with progressive BOS. METHODS From 1991 until now, 239 LTs were performed at our center. Fifty-four patients (22.5%) developed BOS; 15 of these (27.7%) were treated with ECP. At the beginning of the treatment, all patients showed a mean decline of forced expiratory volume in 1 second (FEV1) from baseline values of 45.8% ± 17.2%; 2 patients were in long-term oxygen therapy. RESULTS Mean follow-up from November 2013 to June 2016 was 11.6 ± 7 months. Twelve patients (80%) showed lung function stabilization with an FEV1 range after treatment between -6% to +8% from the pre-treatment values. We did not report any adverse effects or increase of infections incidence. DISCUSSION ECP seems to be an effective and well-tolerated therapeutic option for LT patients with BOS in terms of stabilization of lung function and increased survival.
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Affiliation(s)
- Y Pecoraro
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy.
| | - C Carillo
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - D Diso
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - S Mantovani
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - G Cimino
- Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - T De Giacomo
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - P Troiani
- Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - M Shafii
- Department of Hematology, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - L Gherzi
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - D Amore
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - E A Rendina
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - F Venuta
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
| | - M Anile
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy
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29
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Safavi S, Prayle AP, Hall IP, Parmar J. Azithromycin for treatment of bronchiolitis obliterans syndrome in adult lung transplant recipients. Hippokratia 2017. [DOI: 10.1002/14651858.cd012782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Shahideh Safavi
- School of Medicine, University of Nottingham; Department of Respiratory Medicine; Nottingham UK
| | - Andrew P Prayle
- University of Nottingham; Department of Child Health, School of Clinical Sciences; E Floor East Block, Queens Medical Centre Derby Road Nottingham UK NG7 2UH
| | - Ian P Hall
- School of Medicine, University of Nottingham; Department of Respiratory Medicine; Nottingham UK
| | - Jasvir Parmar
- Papworth Hospital; Department of Transplantation; Papworth Everard Cambridge UK CB23 3RE
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30
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Benden C, Haughton M, Leonard S, Huber LC. Therapy options for chronic lung allograft dysfunction–bronchiolitis obliterans syndrome following first-line immunosuppressive strategies: A systematic review. J Heart Lung Transplant 2017; 36:921-933. [DOI: 10.1016/j.healun.2017.05.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 11/27/2022] Open
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31
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Espinel JDO, Uribe C, Meyer FS, Bringheti R, Kulczynski JU, Saueressig MG. Cell therapy in the treatment of bronchiolitis obliterans in a murine model. Rev Col Bras Cir 2017; 42:181-8. [PMID: 26291260 DOI: 10.1590/0100-69912015003010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/10/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the importance of stem cells derived from adipose tissue in reducing graft inflammation in a murine model of allogeneic heterotopic tracheal transplant. METHODS We performed a heterotopic tracheal allografting in dorsal subcutaneous pouch and systemically injected 5x105 mesenchymal stem cells derived from adipose tissue. The animals were divided into two groups according to the time of sacrifice: T7 and T21. We also carried out histological analysis and digital morphometry. RESULTS The T7 animals treated with cell therapy had median obstructed graft area of 0 versus 0.54 of controls (p = 0.635). The treated T21 subjects had median obstructed graft area of 0.25 versus 0 in controls (p = 0.041). CONCLUSION The systemically injected cell therapy in experimental murine model of bronchiolitis obliterans did not reduce the severity of the allograft inflammation in a statistically significant way in seven days; Conversely, in 21 days, it increased the allograft inflammatory process.
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Affiliation(s)
| | | | | | - Rafael Bringheti
- Universidade Federal de Ciências da Saúde de Porto Alegre, RS, BR
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32
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Peyraga G, Lizee T, Gustin P, Clement-Colmou K, Di Bartolo C, Supiot S, Mahe MA, François S, Mege M. Treatment of cutaneous and/or soft tissue manifestations of corticosteroids refractory chronic graft versus host disease (cGVHD) by a total nodal irradiation (TNI). Clin Transplant 2017; 31. [PMID: 28181304 DOI: 10.1111/ctr.12923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 12/01/2022]
Abstract
The management of corticosteroids refractory chronic graft versus host disease (cGVHD) remains controversial. Retrospective analysis of patients treated at the Integrated Center of Oncology by total nodal irradiation (TNI) was performed to evaluate its therapy potency. TNI delivers a dose of 1 Gy in a single session. The delimitation of the fields is clinical (upper limit: external auditory meatus; lower limit: mid-femur). No pre-therapeutic dosimetry scanner was necessary. Evaluation of the efficacy was by clinical measures at 6 months after the treatment. Twelve patients were treated by TNI between January 2010 and December 2013. TNI was used in second-line treatment or beyond. The median time between allograft and TNI was 31.2 months, and the median time between the first manifestations of cGVHD and TNI was about 24.2 months. Of the 12 patients, nine had a clinical response at 6 months (75%), including five complete clinical responses (41.6%). Five patients could benefit from a reduction of corticosteroid doses. Three patients had hematologic toxicity. TNI could be considered as an option for the treatment of a cutaneous and/or soft tissues corticosteroids refractory cGVHD. However, prospective randomized and double-blind trials remain essential to answer the questions about TNI safety and effectiveness.
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Affiliation(s)
- Guillaume Peyraga
- Department of Radiotherapy, Integrated Center of Oncology, ICO Paul Papin, Angers, France
| | - Thibaut Lizee
- Department of Radiotherapy, Integrated Center of Oncology, ICO Paul Papin, Angers, France
| | - Pierre Gustin
- Department of Radiotherapy, Integrated Center of Oncology, ICO Paul Papin, Angers, France
| | - Karen Clement-Colmou
- Department of Radiotherapy, Integrated Center of Oncology, ICO René Gauducheau, Saint-Herblain, France
| | - Christelle Di Bartolo
- Department of Medical Physics, Integrated Center of Oncology, ICO Paul Papin, Angers, France
| | - Stephane Supiot
- Department of Radiotherapy, Integrated Center of Oncology, ICO René Gauducheau, Saint-Herblain, France
| | - Marc-Andre Mahe
- Department of Radiotherapy, Integrated Center of Oncology, ICO René Gauducheau, Saint-Herblain, France
| | - Sylvie François
- Department of Blood Diseases, University Hospital of Angers, Angers, France
| | - Martine Mege
- Department of Radiotherapy, Integrated Center of Oncology, ICO Paul Papin, Angers, France
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33
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Chambers DC, Enever D, Lawrence S, Sturm MJ, Herrmann R, Yerkovich S, Musk M, Hopkins PMA. Mesenchymal Stromal Cell Therapy for Chronic Lung Allograft Dysfunction: Results of a First-in-Man Study. Stem Cells Transl Med 2017; 6:1152-1157. [PMID: 28186707 PMCID: PMC5442848 DOI: 10.1002/sctm.16-0372] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/16/2016] [Indexed: 12/21/2022] Open
Abstract
Chronic lung transplant rejection (termed chronic lung allograft dysfunction [CLAD]) is the main impediment to long‐term survival after lung transplantation. Bone marrow‐derived mesenchymal stromal cells (MSCs) represent an attractive cell therapy in inflammatory diseases, including organ rejection, given their relative immune privilege and immunosuppressive and tolerogenic properties. Preclinical studies in models of obliterative bronchiolitis and human trials in graft versus host disease and renal transplantation suggest potential efficacy in CLAD. The purpose of this phase 1, single‐arm study was to explore the feasibility and safety of intravenous delivery of allogeneic MSCs to patients with advanced CLAD. MSCs from unrelated donors were isolated from bone marrow, expanded and cryopreserved in a GMP‐compliant facility. Patients had deteriorating CLAD and were bronchiolitis obliterans (BOS) grade ≥ 2 or grade 1 with risk factors for rapid progression. MSCs (2 x 106 cells per kilogram patient weight) were infused via a peripheral vein twice weekly for 2 weeks, with 52 weeks follow‐up. Ten Patients (5 male, 8 bilateral, median [interquartile range] age 40 [30–59] years, 3 BOS2, 7 BOS3) participated. MSC treatment was well tolerated with all patients receiving the full dosing schedule without any procedure‐related serious adverse events. The rate of decline in forced expiratory volume in one second slowed after the MSC infusions (120 ml/month preinfusion vs. 30 ml/month postinfusion, p = .08). Two patients died at 152 and 270 days post‐MSC treatment, both from progressive CLAD. In conclusion, infusion of allogeneic bone marrow‐derived MSCs is feasible and safe even in patients with advanced CLAD. Stem Cells Translational Medicine2017;6:1152–1157
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Affiliation(s)
- Daniel C Chambers
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Debra Enever
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Sharon Lawrence
- Western Australian Lung Transplant Program, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Marian J Sturm
- Department of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia.,Cell & Tissue Therapies Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Richard Herrmann
- Department of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia.,Cell & Tissue Therapies Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Stephanie Yerkovich
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Michael Musk
- Western Australian Lung Transplant Program, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Peter M A Hopkins
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
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34
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Grønningsæter IS, Tsykunova G, Lilleeng K, Ahmed AB, Bruserud Ø, Reikvam H. Bronchiolitis obliterans syndrome in adults after allogeneic stem cell transplantation-pathophysiology, diagnostics and treatment. Expert Rev Clin Immunol 2017; 13:553-569. [DOI: 10.1080/1744666x.2017.1279053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ida Sofie Grønningsæter
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Galina Tsykunova
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Kyrre Lilleeng
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Aymen Bushra Ahmed
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Gauthier JM, Hachem RR, Kreisel D. Update on Chronic Lung Allograft Dysfunction. CURRENT TRANSPLANTATION REPORTS 2016; 3:185-191. [PMID: 28090432 DOI: 10.1007/s40472-016-0112-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) encompasses a range of pathologies that cause a transplanted lung to not achieve or maintain normal function. CLAD manifests as airflow restriction and/or obstruction and is predominantly a result of chronic rejection. Three distinct phenotypes of chronic rejection are now recognized: bronchiolitis obliterans, neutrophilic reversible allograft dysfunction, and restrictive allograft syndrome. Recent investigations have revealed that each phenotype has a unique pathology and histopathological findings, suggesting that treatment regimens should be tailored to the underlying etiology. CLAD is poorly responsive to treatment once diagnosed, and therefore the prevention of the factors that predispose a patient to develop CLAD is critically important. Small and large animal models have contributed significantly to our understanding of CLAD and more studies are needed to develop treatment regimens that are effective in humans.
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Affiliation(s)
- Jason M Gauthier
- Department of Surgery, Washington University in St. Louis, Saint Louis, MO
| | - Ramsey R Hachem
- Department of Medicine, Washington University in St. Louis, Saint Louis, MO
| | - Daniel Kreisel
- Department of Surgery, Washington University in St. Louis, Saint Louis, MO ; Department of Pathology & Immunology, Washington University in St. Louis, Saint Louis, MO
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Burgel PR, Bergeron A, Knoop C, Dusser D. [Small airway diseases and immune deficiency]. Rev Mal Respir 2016; 33:145-55. [PMID: 26854188 DOI: 10.1016/j.rmr.2015.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 06/09/2015] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Innate or acquired immune deficiency may show respiratory manifestations, often characterized by small airway involvement. The purpose of this article is to provide an overview of small airway disease across the major causes of immune deficiency. BACKGROUND In patients with common variable immune deficiency, recurrent lower airway infections may lead to bronchiolitis and bronchiectasis. Follicular and/or granulomatous bronchiolitis of unknown origin may also occur. Bronchiolitis obliterans is the leading cause of death after the first year in patients with lung transplantation. Bronchiolitis obliterans also occurs in patients with allogeneic haematopoietic stem cell transplantation, especially in the context of systemic graft-versus-host disease. VIEWPOINT AND CONCLUSION Small airway diseases have different clinical expression and pathophysiology across various causes of immune deficiency. A better understanding of small airways disease pathogenesis in these settings may lead to the development of novel targeted therapies.
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Affiliation(s)
- P-R Burgel
- Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - A Bergeron
- Université Paris Diderot, Sorbonne Paris Cité, 75013 Paris, France; Service de pneumologie, hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - C Knoop
- Department of Chest Medicine, Erasme University Hospital, université libre de Bruxelles, Bruxelles, Belgique
| | - D Dusser
- Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) was recently introduced as an overarching term covering different phenotypes of chronic allograft dysfunction, including obstructive CLAD (bronchiolitis obliterans syndrome), restrictive CLAD (restrictive allograft syndrome) and graft dysfunction due to causes not related to chronic rejection. In the present review, we will highlight the latest insights and current controversies regarding the new CLAD terminology, underlying pathophysiologic mechanisms, diagnostic approach and possible treatment options. RECENT FINDINGS Different pathophysiological mechanisms are clearly involved in clinically distinct phenotypes of chronic rejection, as is reflected by differences in histology, allograft function and imaging. Therefore, not all CLAD patients may equally benefit from specific therapies. SUMMARY The recent introduction of CLAD importantly changed the clinical practice in lung transplant recipients. Given the relative low accuracy of the current diagnostic tools, future research should focus on specific biomarkers, more sensitive pulmonary function parameters and imaging techniques for timely CLAD diagnosis and phenotyping. Personalized or targeted therapeutic options for adequate prevention and treatment of CLAD are required.
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Hautmann AH, Wolff D, Hilgendorf I, Fehn U, Edinger M, Hoffmann P, Herr W, Kölbl O, Holler B, Sporrer D, Holler E, Hautmann MG. Total nodal irradiation in patients with severe treatment-refractory chronic graft-versus-host disease after allogeneic stem cell transplantation: Response rates and immunomodulatory effects. Radiother Oncol 2015; 116:287-93. [PMID: 26255761 DOI: 10.1016/j.radonc.2015.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 07/13/2015] [Accepted: 07/26/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE The use of total nodal irradiation (TNI) has been reported as an immunomodulatory therapy for different diseases including chronic graft-versus-host disease (cGVHD). MATERIAL AND METHODS We retrospectively analyzed 13 patients with treatment-refractory cGVHD receiving TNI with 1×1Gy from 2001 to 2014. In 10 of 13 patients immunomodulatory effects of TNI were measured. RESULTS At time of TNI all patients had severe cGVHD (involving the skin: n=12), fascia (n=6), oral mucosa (n=8), eye (n=8), and lung (n=5). Nine of 13 patients had corticosteroid-refractory cGVHD. In 7 of 13 patients (54%) a partial response (PR) could be achieved. In 3 patients (23%) cGVHD manifestations remained stable, 2 patients progressed. One patient was not evaluable due to follow-up <1 month. At 3 months after TNI, best responses could be achieved in skin, and oral involvement including steroid sparing activity. TNI was well tolerated with adverse effects limited to reversible thrombocytopenia and neutropenia. Immunomodulatory effects on peripheral blood cells could be demonstrated including an increase of CD4+ T cells in the group of responders. CONCLUSIONS TNI represents an effective immunomodulating therapy in treatment-refractory cGVHD.
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Affiliation(s)
- Anke H Hautmann
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany.
| | - Daniel Wolff
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Inken Hilgendorf
- Department of Internal Medicine (Hematology and Oncology), University Hospital of Rostock, Germany
| | - Ute Fehn
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Petra Hoffmann
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Oliver Kölbl
- Department of Radiotherapy, University Medical Center of Regensburg, Germany
| | - Barbara Holler
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Daniela Sporrer
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III (Hematology and Oncology), University Medical Center of Regensburg, Germany
| | - Matthias G Hautmann
- Department of Radiotherapy, University Medical Center of Regensburg, Germany
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Corris PA, Ryan VA, Small T, Lordan J, Fisher AJ, Meachery G, Johnson G, Ward C. A randomised controlled trial of azithromycin therapy in bronchiolitis obliterans syndrome (BOS) post lung transplantation. Thorax 2015; 70:442-50. [PMID: 25714615 PMCID: PMC4413845 DOI: 10.1136/thoraxjnl-2014-205998] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 01/23/2015] [Indexed: 01/08/2023]
Abstract
Background We conducted a placebo-controlled trial of azithromycin therapy in bronchiolitis obliterans syndrome (BOS) post lung transplantation. Methods We compared azithromycin (250 mg alternate days, 12 weeks) with placebo. Primary outcome was FEV1 change at 12 weeks. Results 48 patients were randomised; (25 azithromycin, 23 placebo). It was established, post randomisation that two did not have BOS. 46 patients were analysed as intention to treat (ITT) with 33 ‘Completers’. ITT analysis included placebo patients treated with open-label azithromycin after study withdrawal. Outcome The ITT analysis (n=46, 177 observations) estimated mean difference in FEV1 between treatments (azithromycin minus placebo) was 0.035 L, with a 95% CI of −0.112 L to 0.182 L (p=0.6). Five withdrawals, who were identified at the end of the study as having been randomised to placebo (four with rapid loss in FEV1, one withdrawn consent) had received rescue open-label azithromycin, with improvement in subsequent FEV1 at 12 weeks. Study Completers showed an estimated mean difference in FEV1 between treatment groups (azithromycin minus placebo) of 0.278 L, with 95% CI for the mean difference: 0.170 L to 0.386 L (p=<0.001). Nine of 23 ITT patients in the azithromycin group had ≥10% gain in FEV1 from baseline. No patients in the placebo group had ≥10% gain in FEV1 from baseline while on placebo (p=0.002). Seven serious adverse events, three azithromycin, four in the placebo group, were deemed unrelated to study medication. Conclusions Azithromycin therapy improves FEV1 in patients with BOS and appears superior to placebo. This study strengthens evidence for clinical practice of initiating azithromycin therapy in BOS. Trial registration number EU-CTR, 2006-000485-36/GB.
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Affiliation(s)
- Paul A Corris
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK Institute of Cellular Medicine, Newcastle upon Tyne, UK
| | - Victoria A Ryan
- Institute of Health and Society Newcastle University, Newcastle upon Tyne, UK
| | - Therese Small
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - James Lordan
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK Institute of Cellular Medicine, Newcastle upon Tyne, UK
| | - Gerard Meachery
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gail Johnson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Chris Ward
- Institute of Cellular Medicine, Newcastle upon Tyne, UK
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Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR. An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44:1479-503. [PMID: 25359357 DOI: 10.1183/09031936.00107514] [Citation(s) in RCA: 380] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
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Affiliation(s)
- Keith C Meyer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ganesh Raghu
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Paul Aurora
- Great Ormond Street Hospital for Children, London, UK
| | | | - Jan Brozek
- McMaster University, Hamilton, ON, Canada
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Verleden GM, Vos R, Dupont L, Van Raemdonck DE, Vanaudenaerde BM, Verleden SE. Are we near to an effective drug treatment for bronchiolitis obliterans? Expert Opin Pharmacother 2014; 15:2117-20. [DOI: 10.1517/14656566.2014.954549] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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McKay C, Knight KA, Wright C. Beyond cancer treatment - a review of total lymphoid irradiation for heart and lung transplant recipients. J Med Radiat Sci 2014; 61:202-9. [PMID: 26229656 PMCID: PMC4175854 DOI: 10.1002/jmrs.63] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 06/01/2014] [Accepted: 06/03/2014] [Indexed: 12/19/2022] Open
Abstract
Immunosuppressive drugs used in the management of heart and lung transplants have a large monetary and quality of life cost due to their side effects. Total lymphoid irradiation (TLI) is one method of minimising the need for or replacing post-operative immunosuppressive drugs. A literature review was conducted on electronic databases using defined search terms. The aim was to establish the indications for the use of TLI, its advantages and disadvantages and the weaknesses associated with the methods used in related research. Eight articles were located that focused on TLI usage in combating organ rejection. These studies identified that the use of TLI resulted in a reduction in early rejection. One study reported a drop in rejection episodes from 0.46 to 0.14 episodes per patient per month once the TLI was complete. While the short-term prognosis is excellent, the long-term outlook is less positive with an increased risk of organ rejection and myelodysplasia 3.5 years post-TLI. This review reminds us that radiation therapy (RT) is not exclusively indicated for cancer treatment. While TLI cannot replace immunosuppressive drug therapy, it can offer a treatment option for people that cannot tolerate immunosuppressive drugs, or when conventional anti-rejection treatment is no longer viable. Reported long-term complications suggest that TLI should be used with caution. However, this modality should not be overlooked in cases of chronic rejection. Further research is required to establish the efficacy of RT in the treatment of transplant patients who are unsuitable for drug-based anti-rejection therapies.
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Affiliation(s)
- Clare McKay
- Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash UniversityClayton, Victoria, Australia
- Correspondence Clare McKay, Department of Medical Imaging and Radiation Sciences, Building 13C, Room 108, School of Biomedical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC 3800, Australia., Tel: +61 3 99052741; Fax: +61 3 99029500; E-mail:
| | - Kellie A Knight
- Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash UniversityClayton, Victoria, Australia
| | - Caroline Wright
- Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash UniversityClayton, Victoria, Australia
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Greer M, Dierich M, De Wall C, Suhling H, Rademacher J, Welte T, Haverich A, Warnecke G, Ivanyi P, Buchholz S, Gottlieb J, Fuehner T. Phenotyping established chronic lung allograft dysfunction predicts extracorporeal photopheresis response in lung transplant patients. Am J Transplant 2013; 13:911-918. [PMID: 23406373 DOI: 10.1111/ajt.12155] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 10/23/2012] [Accepted: 11/11/2012] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality in lung transplant recipients after the first year. Treatment remains limited and unpredictable. Existing data suggests extracorporeal photopheresis (ECP) may be beneficial. This study aimed to identify factors predicting treatment response and the prognostic implications. A single center retrospective analysis of all patients commencing ECP for CLAD between November 1, 2007 and September 1, 2011 was performed. In total 65 patients were included, 64 of whom had deteriorated under azithromycin. Median follow-up after commencing ECP was 503 days. Upon commencing ECP, all patients were classified using proposed criteria for emerging clinical phenotypes, including "restrictive allograft syndrome (RAS)", "neutrophilic CLAD (nCLAD)" and "rapid decliners". At follow-up, 8 patients demonstrated ≥10% improvement in FEV1 , 27 patients had stabilized and 30 patients exhibited ≥10% decline in FEV1 . Patients fulfilling criteria for "rapid decliners" (n=21, p=0.005), RAS (n=22, p=0.002) and those not exhibiting neutrophilia in bronchoalveolar lavage (n=44, p=0.01) exhibited poorer outcomes. ECP appears an effective second line treatment in CLAD patients progressing under azithromycin. ECP responders demonstrated improved progression-free survival (median 401 vs. 133 days). Proposed CLAD phenotypes require refinement, but appear to predict the likelihood of ECP response.
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Affiliation(s)
- M Greer
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - M Dierich
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - C De Wall
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - H Suhling
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - J Rademacher
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - T Welte
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - A Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | - G Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | - P Ivanyi
- Department of Hematology, Hemostasis, Oncology and StemCell Transplantation, Hannover Medical School, Germany
| | - S Buchholz
- Department of Hematology, Hemostasis, Oncology and StemCell Transplantation, Hannover Medical School, Germany
| | - J Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Germany
| | - T Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Germany
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Borthwick LA, Corris PA, Mahida R, Walker A, Gardner A, Suwara M, Johnson GE, Moisey EJ, Brodlie M, Ward C, Perry JD, De Soyza A, Mann DA, Fisher AJ. TNFα from classically activated macrophages accentuates epithelial to mesenchymal transition in obliterative bronchiolitis. Am J Transplant 2013; 13:621-33. [PMID: 23331923 DOI: 10.1111/ajt.12065] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 10/04/2012] [Accepted: 10/08/2012] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome is characterized by fibrotic obliteration of small airways which severely impairs graft function and survival after lung transplantation. Bronchial epithelial cells from the transplanted lung can undergo epithelial to mesenchymal transition and this can be accentuated by activated macrophages. Macrophages demonstrate significant plasticity and change phenotype in response to their microenvironment. In this study we aimed to identify secretory products from macrophages that might be therapeutic targets for limiting the inflammatory accentuation of epithelial to mesenchymal transition in bronchiolitis obliterans syndrome. TNFα, IL-1β and IL-8 are elevated in bronchoalveolar lavage from lung transplant patients prior to diagnosis of bronchiolitis obliterans syndrome. Classically activated macrophages secrete more TNFα and IL-1β than alternatively activated macrophages and dramatically accentuate TGF-β1-driven epithelial to mesenchymal transition in bronchial epithelial cells isolated from lung transplant patients. Blocking TNFα, but not IL-1β, inhibits the accentuation of epithelial to mesenchymal transition. In a pilot unblinded therapeutic intervention in five patients with progressive bronchiolitis obliterans syndrome, anti-TNFα treatment improved forced expiratory volume in 1 second and 6-min walk distances in four patients. Our data identify TNFα as a potential new therapeutic target in bronchiolitis obliterans syndrome deserving of a randomized placebo controlled clinical trial.
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Affiliation(s)
- L A Borthwick
- Tissue Fibrosis and Repair Group, Institute of Cellular Medicine, Newcastle University, UK
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46
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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Lordan JL, Corris PA. Pulmonary arterial hypertension and lung transplantation. Expert Rev Respir Med 2011; 5:441-54. [PMID: 21702664 DOI: 10.1586/ers.11.21] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transplantation remains the only therapeutic option for selected patients with advanced pulmonary arterial hypertension (PAH) who continue to deteriorate despite optimal pulmonary vasodilator therapy - including intravenous prostanoids and combination therapy. Identification of poor prognostic markers in PAH, including persistence in the New York Heart Association functional class III and IV, and adverse pulmonary hemodynamics at right heart catheterization should prompt early referral for transplantation. There is a need for inclusion of more discriminatory markers of PAH prognosis in donor-lung allocation scores to identify patients at risk and optimize survival to transplantation, given the current shortage of donor organ availability worldwide. Double-lung transplantation is the recommended operation for idiopathic PAH. Heart-lung transplantation is reserved for selected patients with idiopathic PAH with severe right ventricular dysfunction, or congenital heart disease with complex or ventricular septal defect-associated PAH. Novel surgical strategies, including atrial septostomy or the pumpless Novalung® lung assist device with conduits, from the pulmonary artery to the left atrium, can be considered as a bridge to transplant for patients with rapid clinical decline, despite maximal medical therapy. Recent transplant outcomes for PAH are encouraging, albeit with early postoperative risks, a requirement for long-term surveillance, immunosuppression and transplant immunosuppression-specific morbidity.
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Affiliation(s)
- James L Lordan
- Applied Immunobiology and Transplantation Group, Institute of Cellular Medicine, Medical School, University of Newcastle upon Tyne, Freeman Hospital, High Heaton, NE7 7DN, UK.
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Hildebrandt GC, Fazekas T, Lawitschka A, Bertz H, Greinix H, Halter J, Pavletic SZ, Holler E, Wolff D. Diagnosis and treatment of pulmonary chronic GVHD: report from the consensus conference on clinical practice in chronic GVHD. Bone Marrow Transplant 2011; 46:1283-95. [PMID: 21441964 PMCID: PMC7094778 DOI: 10.1038/bmt.2011.35] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 11/12/2010] [Accepted: 11/16/2010] [Indexed: 01/03/2023]
Abstract
This consensus statement established under the auspices of the German working group on BM and blood stem cell transplantation (DAG-KBT), the German Society of Hematology and Oncology (DGHO), the Austrian Stem Cell Transplant Working Group, the Swiss Blood Stem Cell Transplantation Group (SBST) and the German-Austrian Pediatric Working Group on SCT (Päd-Ag-KBT) summarizes current evidence for diagnosis, immunosuppressive and supportive therapy to provide practical guidelines for the care and treatment of patients with pulmonary manifestations of chronic GVHD (cGVHD). Pulmonary cGVHD can present with obstructive and/or restrictive changes. Disease severity ranges from subclinical pulmonary function test (PFT) impairment to respiratory insufficiency with bronchiolitis obliterans being the only pulmonary complication currently considered diagnostic of cGVHD. Early diagnosis may improve clinical outcome, and regular post-transplant follow-up PFTs are recommended. Diagnostic work-up includes high-resolution computed tomography, bronchoalveolar lavage and histology. Topical treatment is based on inhalative steroids plus beta-agonists. Early addition of azithromycin is suggested. Systemic first-line treatment consists of corticosteroids plus, if any, continuation of other immunosuppressive therapy. Second-line therapy and beyond includes extracorporeal photopheresis, mammalian target of rapamycin inhibitors, mycophenolate, etanercept, imatinib and TLI, but efficacy is limited. Clinical trials are urgently needed to improve understanding and treatment of this deleterious complication.
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Affiliation(s)
- G C Hildebrandt
- Department of Hematology and Oncology, University of Regensburg Medical Center, Regensburg, Germany.
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50
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Affiliation(s)
- Christiane Knoop
- Department of Chest Medicine, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, B-1070 Brussels, Belgium.
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