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Renaud-Picard B, Koutsokera A, Cabanero M, Martinu T. Acute Rejection in the Modern Lung Transplant Era. Semin Respir Crit Care Med 2021; 42:411-427. [PMID: 34030203 DOI: 10.1055/s-0041-1729542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute cellular rejection (ACR) remains a common complication after lung transplantation. Mortality directly related to ACR is low and most patients respond to first-line immunosuppressive treatment. However, a subset of patients may develop refractory or recurrent ACR leading to an accelerated lung function decline and ultimately chronic lung allograft dysfunction. Infectious complications associated with the intensification of immunosuppression can also negatively impact long-term survival. In this review, we summarize the most recent evidence on the mechanisms, risk factors, diagnosis, treatment, and prognosis of ACR. We specifically focus on novel, promising biomarkers which are under investigation for their potential to improve the diagnostic performance of transbronchial biopsies. Finally, for each topic, we highlight current gaps in knowledge and areas for future research.
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Affiliation(s)
- Benjamin Renaud-Picard
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
| | - Angela Koutsokera
- Division of Pulmonology, Lung Transplant Program, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Cabanero
- Department of Pathology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Tereza Martinu
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
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Aramini B, D’Ovidio F. Gastroesophageal reflux disease and the lung transplant recipient. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13665-014-0092-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Epler GR. Constrictive bronchiolitis obliterans: the fibrotic airway disorder. Expert Rev Respir Med 2014; 1:139-47. [DOI: 10.1586/17476348.1.1.139] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kovacs D, Bikov A, Losonczy G, Murakozy G, Horvath I. Follow up of lung transplant recipients using an electronic nose. J Breath Res 2013; 7:017117. [DOI: 10.1088/1752-7155/7/1/017117] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Nunez-Naveira L, Marinas-Pardo LA, Amor-Carro O, Montero-Martinez C. Determination of ELISA reproducibility to detect protein markers in exhaled breath condensate. J Breath Res 2012; 6:046003. [DOI: 10.1088/1752-7155/6/4/046003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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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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Exhaled breath condensate pH in lung transplant recipients with bronchiolitis obliterans syndrome. Transplantation 2011; 91:793-7. [PMID: 21289593 DOI: 10.1097/tp.0b013e31820d3bc3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Assessment of exhaled breath condensate (EBC) pH is a promising method for investigating airway pathology. However, inaccurate measurement techniques may bias pH readings. In this longitudinal study, we tested whether development of bronchiolitis obliterans syndrome (BOS) in lung transplant recipients is associated with acidification of EBC. METHODS EBC was collected in 15 patients with BOS and 16 stable BOS-free patients during routine clinical visits. From nine BOS patients, samples were collected before and after the onset of BOS, as well. Twenty healthy nontransplant subjects served as controls. EBC pH was measured by the carbon dioxide gas standardization method. RESULTS EBC pH in patients with and without BOS and controls was similar (BOS group: 6.40±0.04, BOS-free group: 6.45±0.03; controls: 6.39±0.02; P>0.05). In patients who developed BOS during the follow-up, EBC pH before and after the onset of BOS was comparable (pre-BOS: 6.41±0.04 vs. post-BOS: 6.41±0.04; P>0.05). Coefficient of variation for repeated pH measurements in controls and subjects with and without BOS was 2.3%±0.3%, 2.0%±0.3%, and 1.7%±0.2%, respectively (P>0.05). Similarly, the limits of agreement for between-visit variability determined by the Bland-Altman test were comparable among the study groups. CONCLUSIONS These data suggest that assessment of EBC pH is of limited value for the diagnosis of BOS.
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Prieto L, Orosa B, Barato D, Marin J. The effect of different periods of argon deaeration on exhaled breath condensate pH. J Asthma 2011; 48:319-23. [PMID: 21385108 DOI: 10.3109/02770903.2011.560321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Exhaled breath condensate (EBC) pH has been considered as a biomarker of airway inflammation in asthma. However, little information is available on the duration of argon deaeration required to achieve a stable pH in EBC samples. OBJECTIVE To identify differences in EBC pH after argon deaeration for 2, 4, and 8 min. METHODS EBC pH was determined in EBC samples from 48 subjects with allergic rhinitis (11 asthmatics) and 14 healthy volunteers without deaeration and after argon deaeration for 2, 4, and 8 min. RESULTS The mean (95% CI) pH values obtained from samples analyzed after 4 min [7.66 (7.52-7.80)] and 8 min [7.70 (7.55-7.85)] of argon deaeration were significantly less acidic (p < .001) than those identified after 2 min of deaeration [7.53 (7.40-7.66)]; differences between pH values at 4 and 8 min were not significant. Furthermore, changes in EBC pH of nondeaerated samples after 4 and 8 min of deaeration were significantly greater than those after 2 min, the mean difference being 0.11 (95% CI, 0.02-0.20, p < .05) and 0.13 (95% CI, 0.04-0.22, p < .01), respectively; differences between changes at 4 and 8 min were not significant. CONCLUSIONS Stabilization of EBC pH is achieved after argon deaeration for 4 min. Therefore, this deaeration period may be recommended instead of the 7-8 min used in several studies.
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Affiliation(s)
- Luis Prieto
- Departamento de Medicina, Facultad de Medicina y Odontologia, Universidad de Valencia, Valencia, Spain.
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Kastelijn EA, Rijkers GT, Van Moorsel CH, Zanen P, Kwakkel-van Erp JM, Van De Graaf EA, Van Kessel DA, Grutters JC, Van Den Bosch JM. Systemic and exhaled cytokine and chemokine profiles are associated with the development of bronchiolitis obliterans syndrome. J Heart Lung Transplant 2010; 29:997-1008. [DOI: 10.1016/j.healun.2010.04.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 04/13/2010] [Accepted: 04/28/2010] [Indexed: 12/13/2022] Open
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Davis CS, Gagermeier J, Dilling D, Alex C, Lowery E, Kovacs EJ, Love RB, Fisichella PM. A review of the potential applications and controversies of non-invasive testing for biomarkers of aspiration in the lung transplant population. Clin Transplant 2010; 24:E54-61. [PMID: 20331688 DOI: 10.1111/j.1399-0012.2010.01243.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite improvements in one-yr survival following lung transplantation, five-yr survival lags significantly behind the transplantation of other solid organs. The contrast in survival persists despite advancements in anti-rejection regimens, suggesting a non-alloimmune mechanism to chronic lung transplant failure. Notably, markers of aspiration have been demonstrated in bronchoalveolar lavage (BAL) fluid concurrent with bronchiolitis obliterans syndrome (BOS). This recent evidence has underscored gastroesophageal reflux (GER) and its associated aspiration risk as a non-alloimmune mechanism of chronic lung transplant failure. Given the suggested safety and efficacy of laparoscopic anti-reflux procedures in the lung transplant population, identifying those at risk for aspiration is of prime importance, especially concerning the potential for long-term improvements in morbidity and mortality. Conventional diagnostic methods for GER and aspiration, such as pH monitoring and detecting pepsin and bile salts in BAL fluid, have gaps in their effectiveness. Therefore, we review the applications and controversies of a non-invasive method of defining reflux injury in the lung transplant population: the detection of biomarkers of aspiration in the exhaled breath condensate. Only by means of assay standardization and directed collaboration may such a non-invasive method be a realization in lung transplantation.
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Affiliation(s)
- C S Davis
- Department of Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
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King BJ, Iyer H, Leidi AA, Carby MR. Gastroesophageal reflux in bronchiolitis obliterans syndrome: a new perspective. J Heart Lung Transplant 2010; 28:870-5. [PMID: 19716037 DOI: 10.1016/j.healun.2009.05.040] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 05/17/2009] [Accepted: 05/18/2009] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Long-term survival after lung transplantation (LTx) is limited largely by bronchiolitis obliterans syndrome (BOS). Gastroesophageal reflux disease (GERD) is proposed as a risk factor for BOS development. This study investigates the relationship between BOS and GERD measured by esophageal impedance. METHODS After the initiation of routine screening for GERD, 59 LTx recipients underwent ambulatory esophageal impedance monitoring. Exposure to acid reflux and non-acid liquid reflux was recorded. Clinical outcomes were reviewed to analyze any effect of reflux on the time to development of BOS. RESULTS Thirty-seven (65%) had abnormal acid reflux and 16 (27%) had abnormal non-acid reflux. There was no relationship between acid reflux and BOS. The hazard ratio (HR) for development of BOS in the presence of abnormal non-acid reflux was 2.8 (p = 0.043). The HR for development of BOS increased to 3.6 (p = 0.022) when the number of acute rejection episodes was also taken into account. CONCLUSIONS GERD is prevalent in LTx recipients and may represent a modifiable risk factor for BOS. This study found non-acid reflux, measured by esophageal impedance to be associated with the development of BOS. Prospective studies are now required to investigate a causal association between GERD and the development of BOS and to establish the role of surgery for GERD in preventing progression to BOS. The methods used to identify GERD in future studies may be important.
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Affiliation(s)
- Benjamin J King
- Department of Transplant Medicine, Harefield Hospital, Harefield, Middlesex, United Kingdom
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Koczulla R, Dragonieri S, Schot R, Bals R, Gauw SA, Vogelmeier C, Rabe KF, Sterk PJ, Hiemstra PS. Comparison of exhaled breath condensate pH using two commercially available devices in healthy controls, asthma and COPD patients. Respir Res 2009; 10:78. [PMID: 19703285 PMCID: PMC2747836 DOI: 10.1186/1465-9921-10-78] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 08/24/2009] [Indexed: 11/10/2022] Open
Abstract
Background Analysis of exhaled breath condensate (EBC) is a non-invasive method for studying the acidity (pH) of airway secretions in patients with inflammatory lung diseases. Aim To assess the reproducibility of EBC pH for two commercially available devices (portable RTube and non-portable ECoScreen) in healthy controls, patients with asthma or COPD, and subjects suffering from an acute cold with lower-airway symptoms. In addition, we assessed the repeatability in healthy controls. Methods EBC was collected from 40 subjects (n = 10 in each of the above groups) using RTube and ECoScreen. EBC was collected from controls on two separate occasions within 5 days. pH in EBC was assessed after degasification with argon for 20 min. Results In controls, pH-measurements in EBC collected by RTube or ECoScreen showed no significant difference between devices (p = 0.754) or between days (repeatability coefficient RTube: 0.47; ECoScreen: 0.42) of collection. A comparison between EBC pH collected by the two devices in asthma, COPD and cold patients also showed good reproducibility. No differences in pH values were observed between controls (mean pH 8.27; RTube) and patients with COPD (pH 7.97) or asthma (pH 8.20), but lower values were found using both devices in patients with a cold (pH 7.56; RTube, p < 0.01; ECoScreen, p < 0.05). Conclusion We conclude that pH measurements in EBC collected by RTube and ECoScreen are repeatable and reproducible in healthy controls, and are reproducible and comparable in healthy controls, COPD and asthma patients, and subjects with a common cold.
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Affiliation(s)
- Rembert Koczulla
- Department of Pulmonology, Leiden University Medical Center, the Netherlands.
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Montuschi P. Analysis of exhaled breath condensate in respiratory medicine: methodological aspects and potential clinical applications. Ther Adv Respir Dis 2009; 1:5-23. [PMID: 19124344 DOI: 10.1177/1753465807082373] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Analysis of exhaled breath condensate (EBC) is a noninvasive method for studying the composition of airway lining fluid and has the potential for assessing lung inflammation. EBC is mainly formed by water vapor, but also contains aerosol particles in which several biomolecules including leukotrienes, 8-isoprostane, prostaglandins, hydrogen peroxide, nitric oxide-derived products, and hydrogen ions, have been detected in healthy subjects. Inflammatory mediators in EBC are detected in healthy subjects and some of them are elevated in patients with different lung diseases. Analysis of EBC is completely noninvasive, is particularly suitable for longitudinal studies, and is potentially useful for assessing the response to pharmacological therapy. Identification of selective profiles of biomarkers of lung diseases might also have a diagnostic value. However, EBC analysis currently has important limitations. The lack of standardized procedures for EBC analysis and validation of some analytical techniques makes it difficult comparison of results from different laboratories. Analysis of EBC is currently more useful for relative measures than for quantitative assessment of inflammatory mediators. Reference analytical techniques are required to provide definitive evidence for the presence of some inflammatory mediators in EBC and for their accurate quantitative assessment in this biological fluid. Several methodological issues need to be addressed before EBC analysis can be considered for clinical applications. However, further research in this area is warranted due to the relative lack of noninvasive methods for assessing lung inflammation.
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Affiliation(s)
- Paolo Montuschi
- Department of Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy.
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Czebe K, Kullmann T, Csiszer E, Barat E, Horvath I, Antus B. Variability of exhaled breath condensate pH in lung transplant recipients. ACTA ACUST UNITED AC 2008; 75:322-7. [PMID: 18042977 DOI: 10.1159/000111819] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 10/02/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Measurement of pH in exhaled breath condensate (EBC) may represent a novel method for investigating airway pathology. OBJECTIVES The aim of this longitudinal study was to assess the variability of EBC pH in stable lung transplant recipients (LTR). METHODS During routine clinical visits 74 EBC pH measurements were performed in 17 LTR. EBC pH was also measured in 19 healthy volunteers on four separate occasions. EBC pH was determined at standard CO2 partial pressure by a blood gas analyzer. RESULTS Mean EBC pH in clinically stable LTR and in controls was similar (6.38 +/- 0.09 vs. 6.44 +/- 0.16; p = nonsignificant). Coefficient of variation for pH in LTR and controls was 2.1 and 2.3%, respectively. The limits of agreement for between-visit variability determined by the Bland-Altman test in LTR and healthy volunteers were also comparable (-0.29 and 0.46 vs. -0.53 and 0.44). CONCLUSIONS Our data suggest that the variability of EBC pH in stable LTR is relatively small, and it is similar to that in healthy nontransplant subjects.
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Affiliation(s)
- Krisztina Czebe
- Department of Pulmonology, National Koranyi Institute for TB and Pulmonology, Budapest, Hungary
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