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Vazquez Guillamet R, Rjob A, Bierhals A, Tague L, Marklin G, Halverson L, Witt C, Byers D, Hachem R, Gierada D, Brody SL, Takahashi T, Nava R, Kreisel D, Puri V, Trulock EP. Potential Role of Computed Tomography Volumetry in Size Matching in Lung Transplantation. Transplant Proc 2023; 55:432-439. [PMID: 36914438 PMCID: PMC10225152 DOI: 10.1016/j.transproceed.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Accumulated knowledge on the outcomes related to size mismatch in lung transplantation derives from predicted total lung capacity equations rather than individualized measurements of donors and recipients. The increasing availability of computed tomography (CT) makes it possible to measure the lung volumes of donors and recipients before transplantation. We hypothesize that CT-derived lung volumes predict a need for surgical graft reduction and primary graft dysfunction. METHODS Donors from the local organ procurement organization and recipients from our hospital from 2012 to 2018 were included if their CT exams were available. The CT lung volumes and plethysmography total lung capacity were measured and compared with predicted total lung capacity using Bland Altman methods. We used logistic regression to predict the need for surgical graft reduction and ordinal logistic regression to stratify the risk for primary graft dysfunction. RESULTS A total of 315 transplant candidates with 575 CT scans and 379 donors with 379 CT scans were included. The CT lung volumes closely approximated plethysmography lung volumes and differed from the predicted total lung capacity in transplant candidates. In donors, CT lung volumes systematically underestimated predicted total lung capacity. Ninety-four donors and recipients were matched and transplanted locally. Larger donor and smaller recipient lung volumes estimated by CT predicted a need for surgical graft reduction and were associated with higher primary graft dysfunction grade. CONCLUSION The CT lung volumes predicted the need for surgical graft reduction and primary graft dysfunction grade. Adding CT-derived lung volumes to the donor-recipient matching process may improve recipients' outcomes.
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Affiliation(s)
- Rodrigo Vazquez Guillamet
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri.
| | - Ashraf Rjob
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Andrew Bierhals
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri
| | - Laneshia Tague
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Gary Marklin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Laura Halverson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Chad Witt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Derek Byers
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Ramsey Hachem
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - David Gierada
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri
| | - Steven L Brody
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri; Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri
| | - Tsuyoshi Takahashi
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Ruben Nava
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Elbert P Trulock
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
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2
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Vazquez Guillamet R, Vazquez Guillamet MC, Rjob A, Bierhals A, Bello I, Abularach AJ, Tague L, Wallendorf M, Marklin GF, Witt C, Byers DE, Kreisel D, Nava R, Puri V, Hachem R, Trulock EP. Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation. J Thorac Dis 2022; 14:1042-1051. [PMID: 35572863 PMCID: PMC9096316 DOI: 10.21037/jtd-21-1755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
Background Errors in measuring chest X-ray (CXR) lung heights could contribute to the occurrence of size-mismatched lung transplant procedures. Methods We first used Bland-Altman analysis for repeated measures to evaluate contributors to measurement error of chest X-ray lung height. We then applied error propagation theory to assess the impact of measurement error on size matching for lung transplantation. Results A total 387 chest X-rays from twenty-five donors and twenty-five recipients were measured by two raters. Individual standard deviation for lung height differences were independent of age, sex, donor vs. recipient, diagnostic group and race/ethnicity and all were pooled for analysis. Bias between raters was 0.27 cm (±0.03) and 0.22 cm (±0.06) for the right and left lung respectively. Within subject variability was the biggest contributor to error in measurement, 2.76 cm (±0.06) and 2.78 cm (±0.2) for the right and left lung height. A height difference of 4.4 cm or more (95% CI: ±4.2, ±4.6 cm) between the donor and the recipient right lung height has to be accepted to ensure matching for at least 95% of patients with the same true lung height. This difference decreases to ±1.1 cm (95% CI: ±0.9, ±1.3 cm) when the average from all available chest X-rays is used. The probability of matching a donor and a recipient decreases with increasing true lung height difference. Conclusions Individual chest X-ray lung heights are imprecise for the purpose of size matching in lung transplantation. Averaging chest X-rays lung heights reduced uncertainty.
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Affiliation(s)
- Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Maria C. Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
- Division of Infectious Diseases at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ashraf Rjob
- Division of Infectious Diseases at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Andrew Bierhals
- Radiology Department at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Irene Bello
- Division of Thoracic Surgery and Lung Transplantation at Vall d’Hebron University Hospital, Barcelona, Spain
| | - Alberto Jauregui Abularach
- Division of Thoracic Surgery and Lung Transplantation at Vall d’Hebron University Hospital, Barcelona, Spain
| | - Laneshia Tague
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael Wallendorf
- Division of Statistics at Washington University School of Medicine, St. Louis, MO, USA
| | | | - Chad Witt
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Derek E. Byers
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Daniel Kreisel
- Division of Thoracic Surgery at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ruben Nava
- Division of Thoracic Surgery at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Varun Puri
- Division of Thoracic Surgery at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Elbert P. Trulock
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
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3
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Tague LK, Bedair B, Witt C, Byers DE, Vazquez-Guillamet R, Kulkarni H, Alexander-Brett J, Nava R, Puri V, Kreisel D, Trulock EP, Gelman A, Hachem RR. Lung protective ventilation based on donor size is associated with a lower risk of severe primary graft dysfunction after lung transplantation. J Heart Lung Transplant 2021; 40:1212-1222. [PMID: 34353713 DOI: 10.1016/j.healun.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/11/2021] [Accepted: 06/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mechanical ventilation immediately after lung transplantation may impact the development of primary graft dysfunction (PGD), particularly in cases of donor-recipient size mismatch as ventilation is typically based on recipient rather than donor size. METHODS We conducted a retrospective cohort study of adult bilateral lung transplant recipients at our center between January 2010 and January 2017. We defined donor-based lung protective ventilation (dLPV) as 6 to 8 ml/kg of donor ideal body weight and plateau pressure <30 cm H2O. We calculated the donor-recipient predicted total lung capacity (pTLC) ratio and used logistic regression to examine relationships between pTLC ratio, dLPV and PGD grade 3 at 48 to 72 hours. We used Cox proportional hazards modelling to examine the relationship between pTLC ratio, dLPV and 1-year survival. RESULTS The cohort included 373 recipients; 24 (6.4%) developed PGD grade 3 at 48 to 72 hours, and 213 (57.3%) received dLPV. Mean pTLC ratio was 1.04 ± 0.18. dLPV was associated with significantly lower risks of PGD grade 3 (OR = 0.44; 95% CI: 0.29-0.68, p < 0.001) and 1-year mortality (HR = 0.49; 95% CI: 0.29-0.8, p = 0.018). There was a significant association between pTLC ratio and the risk of PGD grade 3, but this was attenuated by the use of dLPV. CONCLUSIONS dLPV is associated with decreased risk of PGD grade 3 at 48 to 72 hours and decreased 1-year mortality. Additionally, dLPV attenuates the association between pTLC and both PGD grade 3 and 1-year mortality. Donor-based ventilation strategies may help to mitigate the risk of PGD and other adverse outcomes associated with size mismatch after lung transplantation.
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Affiliation(s)
- Laneshia K Tague
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
| | - Bahaa Bedair
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Chad Witt
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Rodrigo Vazquez-Guillamet
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Hrishikesh Kulkarni
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer Alexander-Brett
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elbert P Trulock
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Andrew Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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4
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Gauthier JM, Doyle MBM, Chapman WC, Marklin G, Witt CA, Trulock EP, Byers DE, Hachem RR, Pasque MK, Meyers BF, Patterson GA, Nava RG, Kozower BD, Kreisel D, Chang SH, Puri V. Economic evaluation of the specialized donor care facility for thoracic organ donor management. J Thorac Dis 2020; 12:5709-5717. [PMID: 33209403 PMCID: PMC7656378 DOI: 10.21037/jtd-20-1575] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Over the last decade two alternative models of donor care have emerged in the United States: the conventional model, whereby donors are managed at the hospital where brain death occurs, and the specialized donor care facility (SDCF), in which brain dead donors are transferred to a SDCF for medical optimization and organ procurement. Despite increasing use of the SDCF model, its cost-effectiveness in comparison to the conventional model remains unknown. Methods We performed an economic evaluation of the SDCF and conventional model of donor care from the perspective of U.S. transplant centers over a 2-year study period. In this analysis, we utilized nationwide data from the Scientific Registry of Transplant Recipients and controlled for donor characteristics and patterns of organ sharing across the nation’s organ procurement organizations (OPOs). Subgroup analysis was performed to determine the impact of the SDCF model on thoracic organ transplants. Results A total of 38,944 organ transplants were performed in the U.S. during the study period from 13,539 donors with an observed total organ cost of $1.36 billion. If every OPO assumed the cost and effectiveness of the SDCF model, a predicted 39,155 organ transplants (+211) would have been performed with a predicted total organ cost of $1.26 billion (−$100 million). Subgroup analysis of thoracic organs revealed that the SDCF model would lead to a predicted 156 additional transplants with a cost saving of $24.6 million. Conclusions The U.S. SDCF model may be a less costly and more effective means of multi-organ donor management, particularly for thoracic organ donors, compared to the conventional hospital-based model.
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Affiliation(s)
- Jason M Gauthier
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Maria B Majella Doyle
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - William C Chapman
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Gary Marklin
- Mid-America Transplant, Washington University School of Medicine, Saint Louis, MO, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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5
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Kulkarni HS, Tsui K, Sunder S, Ganninger A, Tague LK, Witt CA, Byers DE, Trulock EP, Nava R, Puri V, Kreisel D, Mohanakumar T, Gelman AE, Hachem RR. Pseudomonas aeruginosa and acute rejection independently increase the risk of donor-specific antibodies after lung transplantation. Am J Transplant 2020; 20:1028-1038. [PMID: 31677358 PMCID: PMC7103544 DOI: 10.1111/ajt.15687] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/06/2019] [Accepted: 10/24/2019] [Indexed: 01/25/2023]
Abstract
Factors contributing to donor-specific HLA antibody (DSA) development after lung transplantation have not been systematically evaluated. We hypothesized that the isolation of Pseudomonas aeruginosa in respiratory specimens would increase the risk of DSA development. Our objective was to determine the risk of DSA development associated with the isolation of Pseudomonas aeruginosa after lung transplantation. We conducted a single-center retrospective cohort study of primary lung transplant recipients and examined risk factors for DSA development using Cox regression models. Of 460 recipients, 205 (45%) developed DSA; the majority developed Class II DSA (n = 175, 85%), and 145 of 205 (71%) developed DSA to HLA-DQ alleles. Univariate time-dependent analyses revealed that isolation of Pseudomonas from respiratory specimens, acute cellular rejection, and lymphocytic bronchiolitis are associated with an increased risk of DSA development. In multivariable analyses, Pseudomonas isolation, acute cellular rejection, and lymphocytic bronchiolitis remained independent risk factors for DSA development. Additionally, there was a direct association between the number of positive Pseudomonas cultures and the risk of DSA development. Our findings suggest that pro-inflammatory events including acute cellular rejection, lymphocytic bronchiolitis, and Pseudomonas isolation after transplantation are associated with an increased risk of DSA development.
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Affiliation(s)
| | - Kevin Tsui
- Advocate Christ Medical Center, Chicago, IL
| | - Suraj Sunder
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Alex Ganninger
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Laneshia K. Tague
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Chad A. Witt
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Derek E. Byers
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Elbert P. Trulock
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Ruben Nava
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Varun Puri
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | | | - Andrew E. Gelman
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
| | - Ramsey R. Hachem
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
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6
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January SE, Fester KA, Bain KB, Kulkarni HS, Witt CA, Byers DE, Alexander-Brett J, Trulock EP, Hachem RR. Rabbit antithymocyte globulin for the treatment of chronic lung allograft dysfunction. Clin Transplant 2019; 33:e13708. [PMID: 31494969 DOI: 10.1111/ctr.13708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the leading cause of death beyond the first year after lung transplantation. Several treatments have been used to prevent the progression or reverse the effects of CLAD. Cytolytic therapy with rabbit antithymocyte globulin (rATG) has previously shown to be a potential option. However, the effect on patients with restrictive allograft syndrome (RAS) versus bronchiolitis obliterans syndrome (BOS) and the effect of cumulative dosing are unknown. METHODS The charts of lung transplant patients treated with rATG at Barnes-Jewish Hospital from 2009 to 2016 were retrospectively reviewed. The primary outcome was response to rATG; patients were deemed responders if their FEV1 improved in the 6 months after rATG treatment. Safety endpoints included incidence of serum sickness, cytokine release syndrome, malignancy, and infectious complications. RESULTS 108 patients were included in this study; 43 (40%) patients were responders who experienced an increase in FEV1 after rATG therapy. No predictors of response to rATG therapy were identified. Serum sickness occurred in 22% of patients, 15% experienced cytokine release syndrome, and 19% developed an infection after therapy. CONCLUSION 40% of patients with CLAD have an improvement in lung function after treatment with rATG although the improvement was typically minimal.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri
| | | | - Hrishikesh S Kulkarni
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Chad A Witt
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Derek E Byers
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Jennifer Alexander-Brett
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Elbert P Trulock
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Ramsey R Hachem
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
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7
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Gauthier JM, Takahashi T, Bierhals AJ, Brody SL, Hachem RR, Witt CA, Byers DE, Yusen RD, Trulock EP, Aguilar PR, Nava RG, Kozower BD, Meyers BF, Patterson GA, Kreisel D, Puri V. Technical Considerations for Lung Transplantation in Kartagener's Syndrome. Ann Thorac Surg 2018; 107:e337-e339. [PMID: 30612988 DOI: 10.1016/j.athoracsur.2018.08.095] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 11/25/2022]
Abstract
Kartagener's syndrome is a rare genetic disorder of ciliated epithelial cells associated with recurrent respiratory tract infections, bronchiectasis, and situs inversus. In some patients, the accumulation of airway secretions and recurrent infections lead to end-stage lung disease, for which lung transplantation is the only effective treatment. Anatomical variations, such as dextrocardia and pulmonary situs inversus, make the procedure challenging, yet feasible with certain technical modifications and careful preparation of donor lungs. We report a case of bilateral lung transplantation without the use of cardiopulmonary bypass in a patient with Kartagener's syndrome while describing important technical details of the operation.
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Affiliation(s)
- Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Andrew J Bierhals
- Division of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Steven L Brody
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Patrick R Aguilar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Department of Pathology & Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
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8
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Aguilar PR, Carpenter D, Ritter J, Yusen RD, Witt CA, Byers DE, Mohanakumar T, Kreisel D, Trulock EP, Hachem RR. The role of C4d deposition in the diagnosis of antibody-mediated rejection after lung transplantation. Am J Transplant 2018; 18:936-944. [PMID: 28992372 PMCID: PMC5878693 DOI: 10.1111/ajt.14534] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/10/2017] [Accepted: 09/29/2017] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) is an increasingly recognized form of lung rejection. C4d deposition has been an inconsistent finding in previous reports and its role in the diagnosis has been controversial. We conducted a retrospective single-center study to characterize cases of C4d-negative probable AMR and to compare these to cases of definite (C4d-positive) AMR. We identified 73 cases of AMR: 28 (38%) were C4d-positive and 45 (62%) were C4d-negative. The two groups had a similar clinical presentation, and although more patients in the C4d-positive group had neutrophilic capillaritis (54% vs. 29%, P = .035), there was no significant difference in the presence of other histologic findings. Despite aggressive antibody-depleting therapy, 19 of 73 (26%) patients in the overall cohort died within 30 days, but there was no significant difference in freedom from chronic lung allograft dysfunction (CLAD) or survival between the two groups. We conclude that AMR may cause allograft failure, but that the diagnosis requires a multidisciplinary approach and a high index of suspicion. C4d deposition does not appear to be a necessary criterion for the diagnosis, and although some cases may respond initially to therapy, there is a high incidence of CLAD and poor survival after AMR.
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Affiliation(s)
- PR Aguilar
- Baylor University Medical Center Division of Pulmonary & Critical Care, Dallas, TX
| | - D Carpenter
- St. Louis University School of Medicine Department of Pathology, St. Louis, MO
| | - J Ritter
- Washington University School of Medicine Department of Pathology & Immunology, St. Louis, MO
| | - RD Yusen
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - CA Witt
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - DE Byers
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | | | - D Kreisel
- Washington University School of Medicine Division of Cardiothoracic Surgery, St. Louis, MO
| | - EP Trulock
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - RR Hachem
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
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Aguilar PR, Bemiss BC, Witt C, Byers DE, Kreisel D, Puri V, Meyers B, Patterson GA, Krupnick AS, Yusen RD, Trulock EP, Hachem RR. Impact of Delayed Chest Closure on Surgical Site Infection After Lung Transplantation. Ann Thorac Surg 2017; 104:1208-1214. [PMID: 28821338 DOI: 10.1016/j.athoracsur.2017.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 04/23/2017] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delayed chest closure is an increasingly used approach in the management of bleeding and hemodynamic instability after lung transplantation. We sought to evaluate the impact of delayed chest closure on surgical site infection. METHODS We performed a single-center retrospective cohort study and included adult patients who received a lung transplant at our center between January 1, 2010, and July 31, 2014. We defined surgical site infection as a thoracotomy incision wound or pleural space infection. Follow-up was complete through 6 months after transplantation. We used logistic regression models to examine the impact of delayed chest closure on surgical site infection and to identify other potential risk factors. RESULTS During the study period, 67 of the 232 transplant procedures (29%) required delayed chest closure, and surgical site infection developed in 22 recipients (9%). Among the patients with surgical site infection, 18 experienced a wound infection, and 8 experienced a pleural space infection; 4 experienced concomitant wound and pleural space infection. Among the 67 who underwent delayed chest closure, 13 patients (19%) experienced a surgical site infection compared with 9 of the 165 patients (5%) who underwent primary closure (p = 0.001). In multivariate analysis, delayed chest closure was an independent risk factor for surgical site infection. CONCLUSIONS Although delayed chest closure may have an important role in the immediate management of recipients of a lung transplant, it is an independent risk factor for surgical site infection, and this is associated with increased morbidity.
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Affiliation(s)
| | - Bradford C Bemiss
- Division of Pulmonary and Critical Care, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Chad Witt
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander S Krupnick
- Division of Thoracic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Roger D Yusen
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri.
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10
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McGill MR, Vijayan A, Trulock EP, Witt CA, Kohler GD, Scott MG. Falsely Elevated Plasma Creatinine Due to an Immunoglobulin M Paraprotein. Am J Kidney Dis 2016; 68:789-792. [PMID: 27461852 DOI: 10.1053/j.ajkd.2016.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 05/11/2016] [Indexed: 11/11/2022]
Abstract
The most common method for measuring plasma creatinine is based on its reaction with picric acid. However, enzymatic methods are becoming more popular due to improved specificity. We present a case of falsely elevated plasma creatinine values obtained by an enzymatic method that turned out to be due to a monoclonal immunoglobulin M (IgM) paraprotein. A 63-year-old woman evaluated for lung transplantation had falsely increased plasma creatinine levels (1.54-1.71mg/dL; corresponding to estimated glomerular filtration rates of 32-36 mL/min/1.73m2) as measured by the Roche Creatinine plus enzymatic assay when compared with the picric acid-based procedure and several other enzymatic methods, which gave plasma creatinine values of 0.7 to 0.8mg/dL. Serum protein electrophoresis revealed an IgM κ light chain paraprotein. Removal of high-molecular-weight (>30kDa) proteins by ultrafiltration reduced the patient's plasma creatinine level by the Roche enzymatic method to 0.7mg/dL. Addition of the patient's immunoglobulin fraction to plasma from other patients with normal plasma creatinine levels resulted in values that were increased by 0.58 to 0.62mg/dL. Furthermore, removal of non-IgM immunoglobulins with protein G-coupled beads did not eliminate the interference from the patient's plasma. Taken together, these studies demonstrate that falsely elevated plasma creatinine values by the Roche enzymatic method can be due to an IgM paraprotein.
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Affiliation(s)
- Mitchell R McGill
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Anitha Vijayan
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Giselle D Kohler
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Mitchell G Scott
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO.
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11
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Abstract
Major strides have been made in lung transplantation during the 1990s and it has become an established treatment option for patients with advanced lung disease. Due to improvements in organ preservation, surgical techniques, postoperative intensive care, and immunosuppression, the risk of perioperative and early mortality (less than 3 months after transplantation) has declined [1]. The transplant recipient now has a greater chance of realizing the benefits of the long and arduous waiting period.Despite these improvements, suboptimal long-term outcomes continue to be shaped by issues such as opportunistic infections and chronic rejection. Because of the wider use of lung transplantation and the longer life span of recipients, intensivists and ancillary intensive care unit (ICU) staff should be well versed with the care of lung transplant recipients.In this clinical review, issues related to organ donation will be briefly mentioned. The remaining focus will be on the critical care aspects of lung transplant recipients in the posttransplant period, particularly ICU management of frequently encountered conditions. First, the groups of patients undergoing transplantation and the types of procedures performed will be outlined. Specific issues directly related to the allograft, including early graft dysfunction from ischemia-reperfusion injury, airway anastomotic complications, and infections in the setting of immunosuppression will be emphasized. Finally nonpulmonary aspects of posttransplant care and key pharmacologic points in the ICU will be covered.
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12
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Bosanquet JP, Witt CA, Bemiss BC, Byers DE, Yusen RD, Patterson AG, Kreisel D, Mohanakumar T, Trulock EP, Hachem RR. The impact of pre-transplant allosensitization on outcomes after lung transplantation. J Heart Lung Transplant 2015; 34:1415-22. [PMID: 26169666 DOI: 10.1016/j.healun.2015.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/01/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Allosensitization can be a significant barrier to transplantation for some patients, and previous studies suggested that pre-transplant allosensitization was associated with worse outcomes after lung transplantation. However, human leukocyte antigen (HLA) antibody testing has evolved significantly over the past 10 years, and current assays are highly sensitive and specific. METHODS We examined the impact of pre-transplant allosensitization on post-transplant outcomes in the era of solid-phase multiplex HLA antibody detection assays in this retrospective, single-center study of 304 adult transplant recipients between January 1, 2006, and December 31, 2012. We accepted donor organs for allosensitized patients if a virtual crossmatch was compatible with all previously identified antibodies. RESULTS In univariate and multivariate Cox proportional hazards models, pre-transplant allosensitization, the calculated panel reactive antibody, and the number of pre-transplant HLA antibodies were not associated with the development of acute cellular rejection, lymphocytic bronchiolitis, donor-specific HLA antibodies, chronic lung allograft dysfunction, or graft failure. CONCLUSIONS Pre-transplant allosensitization does not adversely affect outcomes after lung transplantation when the potentially reactive HLAs are avoided in the donor by a virtual crossmatch with the recipient.
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Affiliation(s)
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine
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13
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Barbour JR, Yee A, Moore AM, Trulock EP, Buchowski JM, Mackinnon SE. Cadaveric Nerve Allotransplantation in the Treatment of Persistent Thoracic Neuralgia. Ann Thorac Surg 2015; 99:1414-7. [DOI: 10.1016/j.athoracsur.2014.06.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 05/27/2014] [Accepted: 06/03/2014] [Indexed: 10/23/2022]
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14
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Davis LA, Ryszkiewicz E, Schenk E, Peipert J, LaSee C, Miller C, Richardson G, Ridolfi G, Trulock EP, Patterson GA, Waterman A. Lung Transplant or Bust: Patients' Recommendations for Ideal Lung Transplant Education. Prog Transplant 2014; 24:132-41. [DOI: 10.7182/pit2014432] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Context Effective lung transplant education helps ensure informed decision making by patients and better transplant outcomes. Objective To understand the educational needs and experiences of lung transplant patients. Design Mixed-method study employing focus groups and patient surveys. Setting Barnes-Jewish Hospital in St Louis, Missouri. Patients 50 adult lung transplant patients: 23 pretransplant and 27 posttransplant. Main Outcome Measures Patients' interest in receiving specific transplant information, the stage in the transplant process during which they wanted to receive the education, and the preferred format for presenting the information. Results Patients most wanted information about how to sustain their transplant (72%), when to contact their coordinator immediately (56%), transplant benefits (56%), immunosuppressants (54%), and possible out-of-pocket expenses (52%). Patients also wanted comprehensive information early in the transplant process and a review of a subset of topics immediately before transplant (time between getting the call that a potential donor has been found and getting the transplant). Patients reported that they would use Internet resources (74%) and converse with transplant professionals (68%) and recipients (62%) most often. Discussion Lung transplant patients are focused on learning how to get a transplant and ensuring its success afterwards. A comprehensive overview of the evaluation, surgery, and recovery process at evaluation onset with a review of content about medications, pain management, and transplant recovery repeated immediately before surgery is ideal.
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Affiliation(s)
- LaShara A. Davis
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Eric Ryszkiewicz
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Emily Schenk
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - John Peipert
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Claire LaSee
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Carol Miller
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Greg Richardson
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Gene Ridolfi
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Elbert P. Trulock
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - G. Alexander Patterson
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
| | - Amy Waterman
- Saint Barnabas Medical Center, Livingston, New Jersey (LAD), Palo Alto Medical Foundation, Sutter Health, Sunnyvale, California (ER), Washington University School of Medicine, St. Louis, Missouri (ES, CL), David Geffen School of Medicine, University of California, Los Angeles (JP, AW), Barnes-Jewish Hospital, St. Louis, Missouri (CM, GR, GR, EPT, GAP)
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15
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Snell GI, Westall GP, Levvey BJ, Jaksch P, Keshavjee S, Hoopes CW, Ahya V, Mehta A, Trulock EP. A randomized, double-blind, placebo-controlled, multicenter study of rabbit ATG in the prophylaxis of acute rejection in lung transplantation. Am J Transplant 2014; 14:1191-8. [PMID: 24618385 DOI: 10.1111/ajt.12663] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 01/07/2014] [Accepted: 01/07/2014] [Indexed: 01/25/2023]
Abstract
ATG-Fresenius S (ATG-F) is a polyclonal anti-human-T-lymphocyte immunoglobulin preparation that has been clinically developed to prevent episodes of acute cellular rejection. This study evaluated the efficacy and safety of ATG-F at doses of 5 and 9 mg/kg versus placebo in adult recipients of a primary lung allograft. The primary efficacy composite end point was defined as death, graft loss, acute rejection and/or loss to follow-up within 12 months of transplantation. The interim analysis showed the ATG-F 5 mg/kg treatment to be inefficacious, and it would be impossible to enroll enough patients to power the study to show a difference between the 9 mg/kg arm and the placebo arm. Therefore, the main focus of the study shifted to the safety end points and a descriptive analysis of the primary end point. At 12 months posttransplant, the efficacy failure rate was not significantly different between the ATG-F 9 mg/kg group and the placebo group (40.2% vs. 36.7%, respectively). This large study did not demonstrate a significant reduction in acute cellular rejection, graft loss or death with single-dose induction therapy with ATG-F within the first year after lung transplantation.
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Affiliation(s)
- G I Snell
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
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16
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Smith PJ, Blumenthal JA, Carney RM, Freedland KE, O'Hayer CVF, Trulock EP, Martinu T, Schwartz TA, Hoffman BM, Koch GG, Davis RD, Palmer SM. Neurobehavioral functioning and survival following lung transplantation. Chest 2014; 145:604-611. [PMID: 24233282 DOI: 10.1378/chest.12-2127] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Neurobehavioral functioning is widely recognized as being an important consideration in lung transplant candidates, but little is known about whether these factors are related to clinical outcomes. The present study examined the relationship of neurobehavioral functioning, including measures of executive function and memory, depression, and anxiety, to long-term survival among lung transplant recipients. METHODS The sample was drawn from 201 patients who underwent transplantation at Duke University and Washington University who participated in a dual-site clinical trial investigating medical and psychosocial outcomes in transplant candidates with end-stage lung disease. All patients completed the Beck Depression Inventory-II (BDI-II) and Spielberger State-Trait Anxiety Inventory at baseline and again after 12 weeks, while a subset of 86 patients from Duke University also completed neurocognitive testing. Patients were followed for survival up to 12 years after completing baseline assessments. RESULTS One hundred eleven patients died over a mean follow-up of 10.8 years (SD=0.8). Baseline depression, anxiety, and neurocognitive function were examined as predictors of posttransplant survival, controlling for age, 6-min walk distance, FEV, and native disease; education and cardiovascular risk factors were also included in the model for neurocognition. Lower executive function (hazard ratio [HR]=1.09, P=.012) and memory performance (HR=1.11, P=.030) were independently associated with greater mortality following lung transplant. Although pretransplant depression and anxiety were not predictive of mortality, patients who scored>13 on the BDI-II at baseline and after 3 months pretransplant had greater mortality (HR=1.85 [95% CI, 1.04, 3.28], P=.036). CONCLUSIONS Neurobehavioral functioning, including persistently elevated depressive symptoms and lower neurocognitive performance, was associated with reduced survival after lung transplantation. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00113139; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Duke University Health System, Durham, NC.
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Duke University Health System, Durham, NC
| | - Robert M Carney
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | | - Elbert P Trulock
- Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Tereza Martinu
- Department of Medicine, Duke University Medical Center, Duke University Health System, Durham, NC
| | | | - Benson M Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Duke University Health System, Durham, NC
| | - Gary G Koch
- College of Medicine, Drexel University, Philadelphia, PA
| | - R Duane Davis
- Department of Surgery, Duke University Medical Center, Duke University Health System, Durham, NC
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Duke University Health System, Durham, NC
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17
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Witt CA, Gaut JP, Yusen RD, Byers DE, Iuppa JA, Bennett Bain K, Alexander Patterson G, Mohanakumar T, Trulock EP, Hachem RR. Acute antibody-mediated rejection after lung transplantation. J Heart Lung Transplant 2013; 32:1034-40. [PMID: 23953920 DOI: 10.1016/j.healun.2013.07.004] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Antibody-mediated rejection (AMR) after lung transplantation remains enigmatic, and there is no consensus on the characteristic clinical, immunologic and histologic features. METHODS We performed a retrospective, single-center cohort study and identified cases of acute AMR based on the presence of circulating donor-specific human leukocyte antigen (HLA) antibodies (DSA), histologic evidence of acute lung injury, C4d deposition and clinical allograft dysfunction. RESULTS We identified 21 recipients with acute AMR based on the aforementioned criteria. AMR occurred a median 258 days after transplantation; 7 recipients developed AMR within 45 days of transplantation. All patients had clinical allograft dysfunction, DSA, histology of acute lung injury and capillary endothelial C4d deposition. Fifteen recipients improved clinically and survived to hospital discharge, but 6 died of refractory AMR. One survivor had bronchiolitis obliterans syndrome at the time of AMR diagnosis; 13 of the 14 remaining survivors developed chronic lung allograft dysfunction (CLAD) during follow-up. Overall, 15 recipients died during the study period, and the median survival after the diagnosis of AMR was 593 days. CONCLUSIONS Acute AMR can be a fulminant form of lung rejection, and survivors are at increased risk of developing CLAD. The constellation of acute lung injury, DSA and capillary endothelial C4d deposition is compelling for acute AMR in recipients with allograft dysfunction. This clinicopathologic definition requires validation in a multicenter cohort, but may serve as a foundation for future studies to further characterize AMR.
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Affiliation(s)
- Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri.
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18
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Hachem RR, Tiriveedhi V, Patterson GA, Aloush A, Trulock EP, Mohanakumar T. Antibodies to K-α 1 tubulin and collagen V are associated with chronic rejection after lung transplantation. Am J Transplant 2012; 12:2164-71. [PMID: 22568593 PMCID: PMC3409301 DOI: 10.1111/j.1600-6143.2012.04079.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS), the clinical correlate of chronic rejection after lung transplantation, is the leading obstacle to better long-term outcomes. We previously instituted a clinical protocol to screen for donor-specific human leukocyte antigen (HLA) antibodies (DSA) and a preemptive antibody-directed therapy protocol consisting of rituximab and/or intravenous immune globulin. In this study, we retrospectively analyzed serum samples from lung transplant recipients (n = 108) for antibodies to self-antigens (K-α 1 tubulin and collagen V) before and after antibody-directed therapy and correlated the results with the subsequent development of BOS. Seventy-two of the 108 recipients developed antibodies to self-antigens. There was a correlation between the development of antibodies to self-antigens and DSA. Sixteen of the 54 patients who had antibodies to self-antigens and were treated with antibody-directed therapy cleared the antibodies, and they were significantly less likely to develop BOS than those who had persistent antibodies. Furthermore, those who cleared DSA after treatment but had persistent antibodies to self-antigens were significantly more likely to develop BOS than those who cleared these antibodies. We conclude that antibodies to self-antigens are an important risk factor for the development of BOS.
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Affiliation(s)
- R R Hachem
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
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19
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Tiriveedhi V, Angaswamy N, Brand D, Weber J, Gelman AG, Hachem R, Trulock EP, Meyers B, Patterson G, Mohanakumar T. A shift in the collagen V antigenic epitope leads to T helper phenotype switch and immune response to self-antigen leading to chronic lung allograft rejection. Clin Exp Immunol 2012; 167:158-68. [PMID: 22132895 DOI: 10.1111/j.1365-2249.2011.04486.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Immune responses to human leucocyte antigen (HLA) and self-antigen collagen V (Col-V) have been proposed in the pathogenesis of chronic rejection (bronchiolitis obliterans syndrome, BOS) following human lung transplantation (LTx). In this study, we defined the role for the shift in immunodominant epitopes of Col-V in inducing T helper phenotype switch leading to immunity to Col-V and BOS. Sera and lavage from BOS(+) LTx recipients with antibodies to Col-V were analysed. Two years prior to BOS, patients developed antibodies to both Col-V,α1(V) and α2(V) chains. However, at clinical diagnosis of BOS, antibodies became restricted to α1(V). Further, lung biopsy from BOS(+) patients bound to antibodies to α1(V), indicating that these epitopes are exposed. Fourteen Col-V peptides [pep1-14, pep1-4 specific to α1(V), pep5-8 to α1,2(V) and pep9-14 to α2(V)] which bind to HLA-DR4 and -DR7, demonstrated that prior to BOS, pep 6, 7, 9, 11 and 14 were immunodominant and induced interleukin (IL)-10. However, at BOS, the response switched to pep1, 4 and 5 and induced interferon (IFN)-γ and IL-17 responses, but not IL-10. The T helper (Th) phenotype switch is accompanied by decreased frequency of regulatory T cells (T(regs) ) in the lavage. LTx recipients with antibodies to α1(V) also demonstrated increased matrix metalloproteinase (MMP) activation with decreased MMP inhibitor, tissue inhibitor of metalloproteinase (TIMP), suggesting that MMP activation may play a role in the exposure of new Col-V antigenic epitopes. We conclude that a shift in immunodominance of self-antigenic determinants of Col-V results in induction of IFN-γ and IL-17 with loss of tolerance leading to autoimmunity to Col-V, which leads to chronic lung allograft rejection.
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Affiliation(s)
- V Tiriveedhi
- Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
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20
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Bharat A, Kuo E, Saini D, Steward N, Hachem R, Trulock EP, Patterson GA, Meyers BF, Mohanakumar T. Respiratory virus-induced dysregulation of T-regulatory cells leads to chronic rejection. Ann Thorac Surg 2010; 90:1637-44; discussion 1644. [PMID: 20971279 DOI: 10.1016/j.athoracsur.2010.06.048] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 06/01/2010] [Accepted: 06/07/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lower respiratory viral infections predispose to bronchiolitis obliterans syndrome (BOS). In addition, there is emerging evidence to support the role of autoimmunity in the pathogenesis of BOS. Because CD4(+)CD25(+)Foxp3(+) regulatory T-cells (Treg) control autoimmunity, we tested the hypothesis that respiratory virus-induced Treg dysfunction leads to BOS. METHODS Treg frequency was monitored using flow cytometry. Apoptosis, cytokines, and antibodies were analyzed using annexin V assay, LUMINEX, and enzyme-linked immunosorbent assay, respectively. Murine studies were performed using the orthotopic tracheal transplant model. RESULTS (A) Human studies: Treg troughs (decrease >50% of baseline) were found in 13 (43.3%) of 30 lung transplant recipients. Treg isolated during troughs revealed increased apoptosis (37.8%). Patients with Treg troughs had increased prevalence of antibodies to self-antigens collagen type I (23.1% vs 5.8% pretrough), collagen V (7.7% vs 0%), and k-alpha tubulin (30.7% vs 11.7%, p < 0.01) at 6 months post-trough. Increased number of Treg troughs correlated with more rapid onset of BOS. (B) Murine studies: Infection of tracheal transplant recipients with murine parainfleunza sendai virus led to increased Treg apoptosis (50.5%) in the draining lymph nodes. Vaccination against sendai virus prior to transplant abrogated apoptosis of Treg. In vitro, sendai virus-infected, but not naive, tracheal epithelial cells demonstrated upregulation of FasL (>3.5-fold) and induction of co-cultured Treg apoptosis (5.6-fold increase). CONCLUSIONS Respiratory viral infections cause Treg apoptosis which leads to the development of de novo autoimmunity that may play a role in the pathogenesis of BOS.
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Affiliation(s)
- Ankit Bharat
- Department of Surgery/Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Bharat A, Saini D, Steward N, Hachem R, Trulock EP, Patterson GA, Meyers BF, Mohanakumar T. Antibodies to self-antigens predispose to primary lung allograft dysfunction and chronic rejection. Ann Thorac Surg 2010; 90:1094-101. [PMID: 20868794 DOI: 10.1016/j.athoracsur.2010.06.009] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 05/25/2010] [Accepted: 06/01/2010] [Indexed: 01/26/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a known risk factor for bronchiolitis obliterans syndrome (BOS) after lung transplantation. Here, we report that preformed antibodies to self-antigens increase PGD risk and promote BOS. METHODS Adult lung transplant recipients (n = 142) were included in the study. Primary graft dysfunction and BOS were diagnosed based on International Society for Heart and Lung Transplantation guidelines. Antibodies to self-antigens k-alpha-1 tubulin, collagen type V, and collagen I were quantitated using standardized enzyme-linked immunosorbent assays, and cytokines were analyzed using Luminex immunoassays (Biosource International, Camirillo, CA). Human leukocyte antigen (HLA) antibodies were measured using Flow-PRA (One Lambda, Canoga Park, CA). RESULTS Lung transplant recipients with pretransplant antibodies to self-antigens had increased risk of PGD (odds ratio 3.09, 95% confidence interval: 1.2 to 8.1, p = 0.02) compared with recipients without. Conversely, in patients with PGD, 34.7% were positive for pretransplant antibodies whereas in the PGD negative group, only 14.6% had antibodies (p = 0.03). Antibody positive patients demonstrated high levels of proinflammatory cytokines interleukin (IL)-1β (2.1-fold increase), IL-2 (3.0), IL-12 (2.5), IL-15 (3.0), and chemokines interferon-inducible protein-10 (3.9) and monocyte chemotactic protein-1 (3.1; p < 0.01 for all). On 5-year follow-up, patients without antibodies showed greater freedom from development of HLA antibodies compared with patients who had antibodies (class I: 67% versus 38%, p = 0.001; class II: 71% versus 41%, p < 0.001). Patients with pretransplant antibodies were found to have an independent relative risk of 2.3 (95% confidence interval: 1.7 to 4.5, p = 0.009) for developing BOS. CONCLUSIONS Presence of antibodies to self-antigens pretransplant increases the risk of PGD immediately after transplant period and BOS on long-term follow-up. Primary graft dysfunction is associated with an inflammatory cascade that augments the alloimmune (anti-HLA) response that predisposes to BOS.
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Affiliation(s)
- Ankit Bharat
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Tiriveedhi V, Brand D, Hachem R, Trulock EP, Patterson GA, Mohanakumar T. 48-OR: Collagen V Epitope Constraint Leading to Cytokine Switch Following Alloimmune Responses to Mismatched MHC Class I Antigens Which Induces Autoimmunity and Chronic Rejection. Hum Immunol 2010. [DOI: 10.1016/j.humimm.2010.06.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Golocheikine A, Nath DS, Basha HI, Saini D, Phelan D, Aloush A, Trulock EP, Hachem RR, Patterson GA, Ahearn JM, Mohanakumar T. Increased erythrocyte C4D is associated with known alloantibody and autoantibody markers of antibody-mediated rejection in human lung transplant recipients. J Heart Lung Transplant 2010; 29:410-6. [PMID: 20022265 DOI: 10.1016/j.healun.2009.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 10/09/2009] [Accepted: 10/11/2009] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Immune responses to mismatched donor human leukocyte antigens (HLA) are important in the pathogenesis of chronic rejection. This study evaluated whether erythrocyte-bound C4d (E-C4d) is associated with known alloimmune and autoimmune markers of antibody-mediated rejection after human lung transplantation (LTx). METHODS Flow cytometry was used to analyze 22 LTx recipients and 15 healthy individuals for E-C4d. Development of antibodies to donor-mismatched HLA (donor-specific antibody [DSA]) and antibodies to HLA were determined using the solid-phase method by Luminex. Development of antibodies to self-antigens, K-alpha-1-tubulin (KA1T) and collagen V (Col-V), were measured by enzyme-linked immunosorbent assay. C3d deposition in lung biopsy specimens was determined by immunohistochemical staining. RESULTS Percent E-C4d (%E-C4d) levels were 19.9% in LTx patients vs 3.7% in healthy individuals (p = 0.02). DSA+ patients had higher E-C4d levels than DSA- patients (34.1% vs 16.7%, p = 0.02). In 5 patients with preformed anti-HLA, E-C4d levels were not significantly different vs 13 patients without detectable anti-HLA (p = 0.1). E-C4d levels were higher in patients who developed antibodies to KA1T (p = 0.02) and Col-V (p = 0.03). Recipients with C3d-positive tissue deposition had higher E-C4d levels than patients with C3d-negative biopsy results (p = 0.01). CONCLUSIONS Increased %E-C4d levels are found in patients with positive DSA, high antibody titers to KA1T and Col-V, and have C3d+ lung biopsy findings. Therefore, %E-C4d can serve as a potential marker for antibody-mediated rejection after LTx.
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Affiliation(s)
- Angali Golocheikine
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Melby SJ, Larue SJ, Lasala JM, Pal N, Lakshminarasimhachar A, Trulock EP, Kreisel D, Pasque MK, Puri V, Patterson GA, Krupnick AS. Anatomic distortion of the right coronary artery as a complication of lung transplantation. Ann Thorac Surg 2010; 89:2000-1. [PMID: 20494065 DOI: 10.1016/j.athoracsur.2009.10.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 09/22/2009] [Accepted: 10/27/2009] [Indexed: 10/19/2022]
Abstract
Lung transplantation for end-stage chronic obstructive lung disease is now considered the standard of care. We report a case of perioperative myocardial ischemia and cardiovascular compromise in a single lung transplant recipient due to right coronary artery occlusion from mediastinal shift and repositioning of the heart.
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Affiliation(s)
- Spencer J Melby
- Department of Surgery, Division of Cardiothoracic Surgery, Barnes Jewish Hospital, Washington University in St. Louis, St. Louis, Missouri 63110, USA
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Morrell MR, Despotis GJ, Lublin DM, Patterson GA, Trulock EP, Hachem RR. The efficacy of photopheresis for bronchiolitis obliterans syndrome after lung transplantation. J Heart Lung Transplant 2010; 29:424-31. [DOI: 10.1016/j.healun.2009.08.029] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 08/28/2009] [Accepted: 08/30/2009] [Indexed: 12/16/2022] Open
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Jain R, Hachem RR, Morrell MR, Trulock EP, Chakinala MM, Yusen RD, Huang HJ, Mohanakumar T, Patterson GA, Walter MJ. Azithromycin is associated with increased survival in lung transplant recipients with bronchiolitis obliterans syndrome. J Heart Lung Transplant 2010; 29:531-7. [PMID: 20133163 DOI: 10.1016/j.healun.2009.12.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Revised: 11/24/2009] [Accepted: 12/01/2009] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Previous studies have suggested that azithromycin improves lung function in lung transplant recipients with bronchiolitis obliterans syndrome (BOS). However, these studies did not include a non-treated BOS control cohort or perform survival analysis. This study was undertaken to estimate the effect of azithromycin treatment on survival in lung transplant recipients with BOS. METHODS We conducted a retrospective cohort study of consecutive lung transplant recipients who developed BOS between 1999 and 2007. An association between azithromycin treatment and death was assessed using univariate and multivariate time-dependent Cox regression analysis. RESULTS Of the 178 recipients who developed BOS in our study, 78 did so after 2003 and were treated with azithromycin. The azithromycin-treated and untreated cohorts had similar baseline characteristics. Univariate analysis demonstrated that azithromycin treatment was associated with a survival advantage and this beneficial treatment effect was more pronounced when treatment was initiated during BOS Stage 1. Multivariate analysis demonstrated azithromycin treatment during BOS Stage 1 (adjusted hazard ratio = 0.23, p = 0.01) and absolute forced expiratory volume in 1 second (FEV(1)) at the time of BOS Stage 1 (adjusted hazard ratio = 0.52, p = 0.003) were both associated with a decreased risk of death. CONCLUSIONS In lung transplant recipients with BOS Stage 1, azithromycin treatment initiated before BOS Stage 2 was independently associated with a significant reduction in the risk of death. This finding supports the need for a randomized, controlled trial to confirm the impact of azithromycin on survival in lung transplant recipients.
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Affiliation(s)
- Raksha Jain
- Department of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Hachem RR, Patterson GA, Trulock EP. Lung transplantation at Barnes-Jewish Hospital and Washington University in St. Louis. Clin Transpl 2010:227-234. [PMID: 21696044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The lung transplant program at Washington University and Barnes-Jewish Hospital has performed more than 1,000 lung transplants since 1988. The most common operation during this time period has been bilateral-lung transplantation. The LAS has changed lung recipients' diagnoses nationally and at our center. IPF accounts for approximately 25% of recipients at our program and 33% of recipients nationally. Although more severely and acutely ill patients are now coming to transplantation, the long-term outcomes after transplantation have not changed substantially. The incidence of all forms of rejection is high after lung transplantation despite modern immunosuppressive regimens and surveillance techniques. Long-term survival after lung transplantation remains disappointing. In the most recent cohort, the 5-year survival is 64%, but this is significantly worse than survival after kidney, liver, and heart transplantation.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Abstract
Because of our experience with severe Ehrlichia infections in lung transplant recipients, we reviewed all cases of ehrlichiosis in solid organ transplant recipients at Barnes-Jewish Hospital in St. Louis, Missouri. Between 1996 and 2007, 25 cases of ehrlichiosis were identified. We retrospectively collected demographic, clinical, laboratory, and outcomes data, and we compared the 5 cases in lung transplant recipients with 20 cases in other solid organ transplant recipients (heart, 2; kidney, 13; liver, 5). The presenting symptoms in the majority of both groups consisted of fever and headache. Clinical outcomes were worse in the lung transplant group and included a greater need for intensive care unit treatment (80% vs. 20%, P=0.02), longer length of hospital stay (21 vs. 5 days, P=0.02), and propensity to develop acute lung injury or acute respiratory distress syndrome (60% vs. 10%, P=0.04). No mortalities occurred in either group of patients. In an endemic area, ehrlichiosis is not unusual in solid organ transplant recipients, and lung transplant recipients tend to have a more severe illness.
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Affiliation(s)
- K L Lawrence
- Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
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Morrell MR, Patterson GA, Trulock EP, Hachem RR. Acute antibody-mediated rejection after lung transplantation. J Heart Lung Transplant 2008; 28:96-100. [PMID: 19134538 DOI: 10.1016/j.healun.2008.09.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 09/08/2008] [Accepted: 09/29/2008] [Indexed: 01/10/2023] Open
Abstract
The role of humoral immunity after lung transplantation remains unclear. In this report, we describe the pathologic findings and clinical course of a case of acute antibody-mediated rejection (AMR) after lung transplantation. After an uncomplicated early course, a 31-year-old man with cystic fibrosis developed acute graft dysfunction 1 month after bilateral lung transplantation. Lung biopsies showed acute pneumonitis with capillary injury, neutrophilic infiltration and nuclear dust. Immunostaining for C4d demonstrated endothelial cell deposition, and circulating donor-specific human leukocyte antigen (HLA) antibodies were identified. Despite severe hypoxemic respiratory failure, he responded well to a regimen consisting of methylprednisolone, plasma exchange, intravenous immunoglobulin and rituximab therapy. He completely recovered clinically although donor-specific HLA antibodies have remained detectable. The incidence of acute AMR after lung transplantation is unknown, but this case fulfills all of the consensus diagnostic criteria, and we suggest that AMR could be an under-recognized cause of acute graft dysfunction.
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Affiliation(s)
- Matthew R Morrell
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, Missouri, USA.
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Hachem RR, Trulock EP. The new lung allocation system and its impact on waitlist characteristics and post-transplant outcomes. Semin Thorac Cardiovasc Surg 2008; 20:139-42. [PMID: 18707648 DOI: 10.1053/j.semtcvs.2008.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2008] [Indexed: 11/11/2022]
Abstract
Historically, waiting time was the primary determinant of lung organ allocation in the United States. Under this system, waiting time grew progressively longer as the annual number of transplants reached a plateau, and every year, a considerable number of candidates died while waiting. In 2005, the lung allocation system changed; under the new system, priority for transplantation is determined by medical urgency and expected outcome. The lung allocation score is based on survival models that estimate waitlist and post-transplant survival, and reflects the net transplant benefit. Early evaluations of the new system indicate that waiting time has decreased, the total number of transplants has increased, waitlist mortality may be decreasing, and survival after transplantation remains unchanged. Over time, refinements in the lung allocation score will likely reduce waitlist mortality further and maintain or perhaps improve survival after transplantation.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Bharat A, Kuo E, Steward N, Aloush A, Hachem R, Trulock EP, Patterson GA, Meyers BF, Mohanakumar T. Immunological link between primary graft dysfunction and chronic lung allograft rejection. Ann Thorac Surg 2008; 86:189-95; discussion 196-7. [PMID: 18573422 DOI: 10.1016/j.athoracsur.2008.03.073] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 03/26/2008] [Accepted: 03/28/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Primary graft dysfunction (PGD) in the immediate post-lung transplant period strongly increases the risk of chronic rejection (broncholitis obliterans syndrome). Here, we hypothesized that PGD-induced inflammation augments alloimmunity, thereby predisposing to broncholitis obliterans syndrome. METHODS Primary graft dysfunction and broncholitis obliterans syndrome were diagnosed according to the established International Society for Heart and Lung Transplantation criteria. Anti-human leukocyte antigen (HLA) alloantibodies were analyzed using Flow-PRA. Donor HLA class II-specific T cells were analyzed using interferon (IFN)-gamma ELISPOT. Serum levels of 25 cytokines and chemokines were measured using LUMINEX. RESULTS Of the 127 subjects, 29 (22.8%) had no PGD (grade 0), 42 (33.2%) had PGD-1, 36 (28.3%) had PGD-2, and 20 (15.7%) had PGD-3. Patients with PGD grades 1 to 3 (PGD(1-3)) had elevated proinflammatory mediators MCP-1, IP-10, interleukin (IL)-1 beta, IL-2, IFN-gamma, and IL-12 in the sera during the early posttransplant period compared with patients with PGD grade 0 (PGD(0)). On serial analysis, PGD(1-3) patients revealed increased development of de novo anti-HLA-II (5 years: 52.2% versus PGD(0) 13.5%, p = 0.008). However, no difference was found in anti-HLA-I alloantibody development (PGD(1-3) patients 48% versus PGD(0) 39.6%, p = 0.6). Furthermore, PGD(1-3) patients had increased frequency of donor HLA class II-specific CD4(+) T cells [(91.4 +/- 19.37) x 10(-6) versus (23.6 +/- 15.93) x 10(-6), p = 0.003]. CONCLUSIONS Primary graft dysfunction induces proinflammatory cytokines that can upregulate donor HLA-II antigens on the allograft. Increased donor HLA-II expression along with PGD-induced allograft inflammation promotes the development of donor specific alloimmunity. This provides an important mechanistic link between early posttransplant lung allograft injury and reported association with broncholitis obliterans syndrome.
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Affiliation(s)
- Ankit Bharat
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Hachem RR, Edwards LB, Yusen RD, Chakinala MM, Alexander Patterson G, Trulock EP. The impact of induction on survival after lung transplantation: an analysis of the International Society for Heart and Lung Transplantation Registry. Clin Transplant 2008; 22:603-8. [PMID: 18435784 DOI: 10.1111/j.1399-0012.2008.00831.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of induction immunosuppression after lung transplantation remains controversial. In this study, we examined the impact of induction on survival after lung transplantation. METHODS We performed a retrospective cohort study of 3970 adult lung transplant recipients reported to the ISHLT Registry. We divided the cohort into three groups based on the use of induction: none, interleukin-2 receptor antagonists (IL-2 RA), and polyclonal antithymocyte globulins (ATG). We estimated graft survival using the Kaplan-Meier method and constructed a multivariable Cox proportional hazards model to examine the impact of induction on graft survival in the context of other variables. RESULTS During the study period, 2249 patients received no induction, 1124 received IL-2 RA, and 597 received ATG. Four years after transplantation, recipients treated with IL-2 RA had better graft survival (64%) than those treated with ATG (60%) and those who did not receive induction (57%; log rank p = 0.0067). This survival advantage persisted in the multivariable model for single and bilateral recipients treated with IL-2 RA compared to those who did not receive induction (RR = 0.82, p = 0.007). Similarly, bilateral recipients treated with ATG had a survival advantage over bilateral recipients who did not receive induction (RR = 0.78, p = 0.043), but single lung recipients treated with ATG did not have a survival advantage over single lung recipients who did not receive induction (RR = 1.06, p = 0.58). CONCLUSIONS Induction with lL-2 RA for single and bilateral lung recipients and induction with ATG for bilateral recipients are associated with a survival benefit, independent of other variables that might impact survival.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, St. Louis, MO, USA.
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Aurora P, Boucek MM, Christie J, Dobbels F, Edwards LB, Keck BM, Rahmel AO, Taylor DO, Trulock EP, Hertz MI. Registry of the International Society for Heart and Lung Transplantation: tenth official pediatric lung and heart/lung transplantation report--2007. J Heart Lung Transplant 2007; 26:1223-8. [PMID: 18096472 DOI: 10.1016/j.healun.2007.07.035] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 06/14/2007] [Accepted: 07/23/2007] [Indexed: 10/22/2022] Open
Abstract
This tenth official pediatric report of the International Society for Heart and Lung Transplantation (ISHLT) covers the international pediatric lung and heart-lung transplantation experience from 1982 to 2006. As of last year's report, pediatric lung and heart-lung transplant data are now reported separately from pediatric heart transplant data and adult lung transplant data. For the first time this year, Registry data are analyzed by geographic region in addition to the usual aggregate analyses. All figures and tables included in this report and additional supplementary slides are available from the ISHLT website (www.ishlt.org/registries).
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Affiliation(s)
- Paul Aurora
- International Society for Heart and Lung Transplantation, Addison, Texas, USA.
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Hachem RR, Yusen RD, Chakinala MM, Meyers BF, Lynch JP, Aloush AA, Patterson GA, Trulock EP. A randomized controlled trial of tacrolimus versus cyclosporine after lung transplantation. J Heart Lung Transplant 2007; 26:1012-8. [PMID: 17919621 DOI: 10.1016/j.healun.2007.07.027] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Revised: 07/11/2007] [Accepted: 07/15/2007] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The optimal maintenance immunosuppressive regimen after lung transplantation is uncertain. METHODS We conducted a randomized controlled trial of tacrolimus versus cyclosporine in combination with azathioprine and prednisone after lung transplantation. Ninety adults were randomized to tacrolimus (n = 44) or cyclosporine (n = 46). The primary end point was a composite of a cumulative acute rejection A score of 3 or higher, a cumulative lymphocytic bronchitis B score of 4 or higher, or the onset of bronchiolitis obliterans syndrome (BOS) stage 0-p. RESULTS Recipients randomized to cyclosporine were significantly more likely to develop the primary end point than those randomized to tacrolimus. During the study period, the primary end point developed in 39 of 46 cyclosporine subjects compared with 24 of 44 tacrolimus subjects (p = 0.002); acute rejection or lymphocytic bronchitis end points developed in 29 of 46 cyclosporine subjects compared with 18 of 44 tacrolimus subjects (p = 0.036). Furthermore, BOS stage 0-p was more likely to develop in the cyclosporine group than in the tacrolimus group, but this was not statistically significant (log-rank p = 0.1). In addition, there was a trend to a higher incidence of diabetes among those in the tacrolimus group, but there was no significant difference in graft survival or the total number of infections, or in the incidence of hypertension, chronic kidney disease, or cancer between the 2 groups. CONCLUSIONS Tacrolimus is associated with a lower burden of acute rejection and lymphocytic bronchitis and a trend to a greater freedom from BOS stage 0-p than cyclosporine after lung transplantation.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Hertz MI, Aurora P, Boucek MM, Christie JD, Dobbels F, Edwards LB, Keck BM, Rahmel AO, Rowe AW, Taylor DO, Trulock EP. Registry of the International Society for Heart and Lung Transplantation: Introduction to the 2007 Annual Reports—100,000 Transplants and Going Strong. J Heart Lung Transplant 2007; 26:763-8. [DOI: 10.1016/j.healun.2007.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 06/18/2007] [Accepted: 06/25/2007] [Indexed: 11/26/2022] Open
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Hertz MI, Boucek MM, Edwards LB, Keck BM, Rowe AW, Taylor DO, Trulock EP, Waltz DA. The ISHLT transplant registry: moving forward. J Heart Lung Transplant 2007; 25:1179-85. [PMID: 17045929 DOI: 10.1016/j.healun.2006.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Revised: 06/22/2006] [Accepted: 07/17/2006] [Indexed: 11/30/2022] Open
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Bharat A, Fields RC, Trulock EP, Patterson GA, Mohanakumar T. Induction of IL-10 suppressors in lung transplant patients by CD4+25+ regulatory T cells through CTLA-4 signaling. J Immunol 2007; 177:5631-8. [PMID: 17015751 DOI: 10.4049/jimmunol.177.8.5631] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
T cell-mediated autoimmunity to collagen V (col-V), a sequestered yet immunogenic self-protein, can induce chronic lung allograft rejection in rodent models. In this study we characterized the role of CD4+ CD25+ regulatory T cells (Tregs) in regulating col-V autoimmunity in human lung transplant (LT) recipients. LT recipients revealed a high frequency of col-V-reactive, IL-10-producing CD4+ T cells (T IL-10 cells) with low IL-2-, IFN-gamma-, IL-5-, and no IL-4-producing T cells. These T(IL-10) cells were distinct from Tregs because they lacked constitutive expression of both CD25 and Foxp3. Expansion of T IL-10 cells during col-V stimulation in vitro involved CTLA-4 on Tregs, because both depleting and blocking Tregs with anti-CTLA4 F(ab')2 mAbs resulted in loss of T IL-10 cells with a concomitant increase in IFN-gamma producing Th1 cells (TIFN-gamma cells). A Transwell culture of col-V-specific T IL-10 cells with Th1 cells (those generated in absence of Tregs) from the same patient resulted in marked inhibition of IFN-gamma and proliferation of T(IFN-gamma) cells, which was reversed by neutralizing IL-10. Furthermore, the T IL-10 cells were HLA class II restricted because blocking HLA class II on APCs resulted in the loss of IL-10 production. Chronic lung allograft rejection was associated with the loss of Tregs with a concomitant decrease in T IL-10 cells and an increase in T IFN-gamma cells. We conclude that LT patients have col-V-specific T cells that can be detected in the peripheral blood. The predominant col-V-specific T cells produce IL-10 that suppresses autoreactive Th1 cells independently of direct cellular contact. Tregs are pivotal for the induction of these "suppressor" T IL-10 cells.
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Affiliation(s)
- Ankit Bharat
- Department of Surgery, Washington University School of Medicine, St. Louis. MO 63110, USA
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Chen F, Hasegawa S, Bando T, Kitaichi M, Hiratsuka T, Kawashima M, Hanaoka N, Yoshimura T, Tanaka F, Trulock EP, Wada H. Recurrence of bilateral diffuse bronchiectasis after bilateral lung transplantation. Respirology 2007; 11:666-8. [PMID: 16916346 DOI: 10.1111/j.1440-1843.2006.00904.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We report two cases of bilateral diffuse bronchiectasis in which early recurrence of the original lung disease occurred after bilateral lung transplantation (LT). Patient 1 underwent cadaveric LT. Recurrent bronchiectasis occurred 4 months later, and he died 6 years after LT. Patient 2 underwent living-related lobar LT, bronchiectasis relapsed 4 months later, and he died 13 months after LT. Both cases were finally diagnosed as bilateral diffuse bronchiectasis by the pathological features of the explanted lungs: infiltration of inflammatory cells predominantly in the conducting airways with dilation of the bronchi of bilateral lungs and scarcity of foamy macrophages in the wall of the respiratory bronchioles. Similar pathological features were seen in autopsy specimens from patient 1 and a transbronchial biopsy specimen from patient 2. LT should be carried out with caution in patients with bilateral diffuse bronchiectasis. When performing LT in such patients, it is suggested that sinusitis should be controlled perioperatively.
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Affiliation(s)
- Fengshi Chen
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
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Bharat A, Narayanan K, Street T, Fields RC, Steward N, Aloush A, Meyers B, Schuessler R, Trulock EP, Patterson GA, Mohanakumar T. Early Posttransplant Inflammation Promotes the Development of Alloimmunity and Chronic Human Lung Allograft Rejection. Transplantation 2007; 83:150-8. [PMID: 17264811 DOI: 10.1097/01.tp.0000250579.08042.b6] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Chronic human lung allograft rejection, represented by bronchiolitis obliterans syndrome (BOS), is the single most important factor that limits the long-term survival following lung transplantation (LT). However, the pathogenesis of BOS remains unclear. We hypothesized that the early posttransplant inflammation would promote the development of donor anti-human leukocyte antigen (HLA) alloimmunity and predispose to BOS. METHODS Serum levels of interleukin (IL)-1beta, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, Eotaxin, IP-10, MIG, MCP-1, MIP-1alpha, MIP-1beta, RANTES, tumor necrosis factor (TNF)-alpha, interferon (IFN)-alpha, IFN-gamma, granulocyte-macrophage colony-stimulating factor, IL-1Ralpha, and IL-2R were serially analyzed in 31 BOS+ and matched 31 BOS- patients using quantitative multiplex bead immunoassays. Donor-specific HLA class II cellular immunity was analyzed using enzyme-linked immunospot (ELISPOT) by testing recipient peripheral blood mononuclear cells against mismatched donor HLA-DR peptides. Anti-HLA class II antibodies were monitored using flow panel reactive antibodies. RESULTS There was early posttransplant elevation in basal serum levels of proinflammatory chemokines IP-10 and MCP-1 and Th1-cytokines IL-1beta, IL-2, IL-12, and IL-15 in BOS+ patients, compared to BOS- and normal subjects. In addition, a threefold decline in IL-10 levels was found during BOS development. BOS+ patients revealed increased development of HLA class II alloantibodies and Th1-predominant donor-specific cellular immunity with high frequency of IFN-gamma and low IL-5 producing T-cells. CONCLUSION Early posttransplant elevation of proinflammatory mediators is associated with alloimmunity and chronic human lung allograft rejection.
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Affiliation(s)
- Ankit Bharat
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Fields RC, Bharat A, Steward N, Aloush A, Meyers BF, Trulock EP, Chapman WC, Patterson GA, Mohanakumar T. Elevated Soluble CD30 Correlates with Development of Bronchiolitis Obliterans Syndrome Following Lung Transplantation. Transplantation 2006; 82:1596-601. [PMID: 17198242 DOI: 10.1097/01.tp.0000241076.46033.4c] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The long-term function of lung transplants is limited by chronic rejection (bronchiolitis obliterans syndrome, BOS). Due to lack of specific markers, BOS is diagnosed clinically. Because there is strong evidence that alloimmunity plays a significant role in the pathogenesis of BOS, we investigated whether soluble CD30 (sCD30), a T-cell activation marker, would correlate with BOS. METHODS Sera collected serially from BOS+ (n = 20) and matched BOS- (n = 20) lung transplant (LT) patients were analyzed for sCD30 by enzyme-linked immunosorbent assay. Pretransplant sera and sera from normal donors were also analyzed. RESULTS PreLT levels were comparable to normal subjects. However, posttransplant there was a significant elevation in sCD30 levels during BOS development in all BOS+ patients, compared to BOS- (mean 139.8+/-10.7 vs. 14.8+/-2.7 U/ml, P < 0.001). sCD30 levels declined in the BOS+ patients but were still elevated compared to BOS- (48.52+/-5.04 vs. 7.19+/-2.9, P < 0.0001). CONCLUSIONS We conclude that sCD30 may represent a novel marker to monitor the development of BOS.
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Affiliation(s)
- Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Daud SA, Yusen RD, Meyers BF, Chakinala MM, Walter MJ, Aloush AA, Patterson GA, Trulock EP, Hachem RR. Impact of immediate primary lung allograft dysfunction on bronchiolitis obliterans syndrome. Am J Respir Crit Care Med 2006; 175:507-13. [PMID: 17158279 DOI: 10.1164/rccm.200608-1079oc] [Citation(s) in RCA: 278] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Primary graft dysfunction is a common complication after lung transplantation and a significant risk factor for short- and long-term mortality. OBJECTIVE We examined the impact of primary graft dysfunction on bronchiolitis obliterans syndrome. METHODS We performed a retrospective cohort study of 334 adult lung transplant recipients at our program and graded the severity of primary graft dysfunction according to the International Society for Heart and Lung Transplantation definition. We evaluated the impact of primary graft dysfunction on acute rejection, lymphocytic bronchitis, and bronchiolitis obliterans syndrome stage 1, using univariable and multivariable Cox proportional hazards models. MAIN RESULTS Among the 334 recipients, 65 did not have primary graft dysfunction (grade 0), 130 had grade 1, 69 had grade 2, and 70 had grade 3. In the univariable analysis, all grades of primary graft dysfunction were associated with a significantly increased risk of bronchiolitis obliterans syndrome stage 1 (grade 1: relative risk [RR] = 1.73; grade 2: RR = 2.13; and grade 3: RR = 2.53, compared with grade 0). The multivariable model demonstrated that the increased risk of bronchiolitis obliterans syndrome associated with primary graft dysfunction was independent of acute rejection, lymphocytic bronchitis, and community-acquired respiratory viral infections. However, there was no association between primary graft dysfunction and acute rejection or lymphocytic bronchitis. CONCLUSIONS Primary graft dysfunction is associated with an increased risk of bronchiolitis obliterans syndrome independent of acute rejection, lymphocytic bronchitis, and community-acquired respiratory viral infections, and this risk is directly related to the severity of primary graft dysfunction.
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Affiliation(s)
- Shiraz A Daud
- Division of Pulmonary and Critical Care, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8052, St. Louis, MO 63110, USA
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Willey PA, Phelan DL, Hachem RR, Trulock EP, Mohanakumar T. 207-P. Hum Immunol 2006. [DOI: 10.1016/j.humimm.2006.08.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Choong CK, Meyers BF, Guthrie TJ, Trulock EP, Patterson GA, Moazami N. Does the presence of preoperative mild or moderate coronary artery disease affect the outcomes of lung transplantation? Ann Thorac Surg 2006; 82:1038-42. [PMID: 16928531 DOI: 10.1016/j.athoracsur.2006.03.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Revised: 03/10/2006] [Accepted: 03/15/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Significant coronary artery disease (CAD) is an exclusion criterion for lung transplantation at most centers. However, the impact of preoperative noncritical CAD (single or multivessel mild <30% or moderate 30% to 50% stenosis) on the outcomes of lung transplantation is unknown. METHODS A retrospective review of 268 adult patients who underwent lung transplantation between June 1998 and June 2003 at Barnes-Jewish Hospital, a tertiary care center affiliated with Washington University School of Medicine, was performed. RESULTS Two hundred ten patients had coronary angiography performed as part of their pretransplantation evaluation. Among these patients, 177 patients had no CAD, and 33 patients (mild, 16; moderate, 17) had noncritical CAD. Patients with noncritical CAD were older (59 versus 55 years, p < 0.001) and had a higher prevalence of diabetes (24% versus 9%, p = 0.014) and systemic hypertension (58% versus 36%, p = 0.004) than patients without CAD. There was no significant difference in the underlying lung disease, other comorbidities, type of lung transplantation performed, early postoperative complications, and hospital or late mortality between recipients with or without CAD. Among the patients with noncritical CAD, there was no hospital mortality and no late cardiac mortality. Three recipients with preoperative moderate CAD developed late ischemic cardiac events, and revascularization was performed in 2 of these recipients. Long-term survival was similar among recipients with or without preoperative CAD. CONCLUSIONS Preoperative noncritical (mild or moderate) CAD was not associated with increased perioperative morbidity or mortality, and it did not adversely affect short-term or long-term survival. Late ischemic events developed in 18% of the recipients with moderate CAD disease with no effect on mortality.
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Affiliation(s)
- Cliff K Choong
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Waltz DA, Boucek MM, Edwards LB, Keck BM, Trulock EP, Taylor DO, Hertz MI. Registry of the International Society for Heart and Lung Transplantation: Ninth Official Pediatric Lung and Heart–Lung Transplantation Report—2006. J Heart Lung Transplant 2006; 25:904-11. [PMID: 16890110 DOI: 10.1016/j.healun.2006.06.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 05/31/2006] [Accepted: 06/04/2006] [Indexed: 11/19/2022] Open
Affiliation(s)
- David A Waltz
- International Society for Heart and Lung Transplantation, Addison, Texas, USA.
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Boucek MM, Waltz DA, Edwards LB, Taylor DO, Keck BM, Trulock EP, Hertz MI. Registry of the International Society for Heart and Lung Transplantation: Ninth Official Pediatric Heart Transplantation Report—2006. J Heart Lung Transplant 2006; 25:893-903. [PMID: 16890109 DOI: 10.1016/j.healun.2006.05.014] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 05/26/2006] [Accepted: 06/01/2006] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mark M Boucek
- International Society for Heart and Lung Transplantation, Addison, Texas, USA.
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Trulock EP, Edwards LB, Taylor DO, Boucek MM, Keck BM, Hertz MI. Registry of the International Society for Heart and Lung Transplantation: Twenty-third Official Adult Lung and Heart–Lung Transplantation Report—2006. J Heart Lung Transplant 2006; 25:880-92. [PMID: 16890108 DOI: 10.1016/j.healun.2006.06.001] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 05/26/2006] [Accepted: 06/01/2006] [Indexed: 11/30/2022] Open
Affiliation(s)
- Elbert P Trulock
- International Society for Heart and Lung Transplantation, Addison, Texas, USA.
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Bharat A, Fields RC, Steward N, Trulock EP, Patterson GA, Mohanakumar T. CD4+25+ regulatory T cells limit Th1-autoimmunity by inducing IL-10 producing T cells following human lung transplantation. Am J Transplant 2006; 6:1799-808. [PMID: 16889540 DOI: 10.1111/j.1600-6143.2006.01383.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chronic human lung allograft rejection is manifested by bronchiolitis obliterans syndrome (BOS). BOS has a multifactorial etiology. Previous studies have indicated that both cellular and humoral alloimmunity play a significant role in the pathogenesis of BOS. Recently, autoimmunity has also been demonstrated to contribute to lung allograft rejection in animal models. However, the significance of autoimmunity in BOS remains unknown. In this report, we investigated the role of naturally occurring CD4(+)CD25(+) regulatory T cells (T-regs) in modulating cellular autoimmunity to collagen type V (col-V), a 'sequestered' yet immunogenic self-protein present in the lung tissue, following lung transplantation (LT). We demonstrated that col-V reactive CD4(+) T cells could be detected in the peripheral blood of lung transplant recipients. There was a predominance of IL-10 producing T cells (T(IL-10)) reactive to col-V with significantly lower levels of IFN-gamma and IL-2 producing T cells (Th1 cells). The col-V specific T(IL-10) cells suppressed the proliferation and expansion of col-V specific Th1 cells by IL-10-dependent and contact-independent pathways. The T(IL-10) cells were distinct but their development was dependent on the presence of T-regs. Furthermore, during chronic lung allograft rejection there was a significant decline of T(IL-10) cells with concomitant expansion of col-V-specific IFN-gammaproducing Th1 cells.
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Affiliation(s)
- A Bharat
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Taylor DO, Edwards LB, Boucek MM, Trulock EP, Waltz DA, Keck BM, Hertz MI. Registry of the International Society for Heart and Lung Transplantation: Twenty-third Official Adult Heart Transplantation Report—2006. J Heart Lung Transplant 2006; 25:869-79. [PMID: 16890107 DOI: 10.1016/j.healun.2006.05.002] [Citation(s) in RCA: 276] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Revised: 05/05/2006] [Accepted: 05/15/2006] [Indexed: 11/29/2022] Open
Affiliation(s)
- David O Taylor
- International Society for Heart and Lung Transplantation, Addison, Texas, USA.
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Hachem RR, Chakinala MM, Yusen RD, Lynch JP, Aloush AA, Patterson GA, Trulock EP. A comparison of basiliximab and anti-thymocyte globulin as induction agents after lung transplantation. J Heart Lung Transplant 2006; 24:1320-6. [PMID: 16143251 DOI: 10.1016/j.healun.2004.09.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Revised: 08/29/2004] [Accepted: 09/04/2004] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Interleukin-2 receptor antagonists have supplanted polyclonal antibody preparations as the most frequently used induction agents after lung transplantation, but the relative efficacy of these agents has not been firmly established. METHODS We retrospectively analyzed the efficacy of basiliximab compared with antithymocyte globulin among 157 adult lung transplant recipients at our center. RESULTS At 3, 6, and 12 months after transplantation, the median cumulative acute rejection A scores for the basiliximab group (2, 2, and 3, respectively) were significantly higher than those for the anti-thymocyte globulin group (1, 1, and 2, respectively; p = 0.003, 0.004, and 0.033, respectively). In addition, basiliximab recipients were more likely to develop acute rejection grade > or = A2 than anti-thymocyte globulin recipients; in fact, 60% of basiliximab recipients compared with 38% of anti-thymocyte globulin recipients developed their first episode of acute rejection grade > or = A2 in the first 100 days after transplantation (log-rank p = 0.04). Furthermore, basiliximab recipients were more likely to develop bronchiolitis obliterans syndrome than anti-thymocyte globulin recipients (log-rank p = 0.036). Two years after transplantation, 36% of basiliximab recipients and 26% of anti-thymocyte globulin recipients developed bronchiolitis obliterans syndrome. However, there were no significant differences in the incidences of cytomegalovirus viremia and pneumonitis between the 2 groups (p = 0.86 and 0.89, respectively). CONCLUSIONS Induction with anti-thymocyte globulin is associated with a lower burden of acute rejection and bronchiolitis obliterans syndrome compared with basiliximab, without a significant difference in the incidence of cytomegalovirus infections.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Mikols CL, Yan L, Norris JY, Russell TD, Khalifah AP, Hachem RR, Chakinala MM, Yusen RD, Castro M, Kuo E, Patterson GA, Mohanakumar T, Trulock EP, Walter MJ. IL-12 p80 is an innate epithelial cell effector that mediates chronic allograft dysfunction. Am J Respir Crit Care Med 2006; 174:461-70. [PMID: 16728708 PMCID: PMC2648123 DOI: 10.1164/rccm.200512-1886oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Bronchiolitis obliterans syndrome is the leading cause of chronic lung allograft dysfunction. We have demonstrated that respiratory viral infection is a bronchiolitis obliterans syndrome risk factor and virus-dependent injury induces expression of innate airway epithelial genes belonging to the interleukin (IL)-12 family. Thus, we hypothesized that epithelial cell IL-12 family members could mediate lung allograft dysfunction. OBJECTIVES We used mouse and human allograft specimens to evaluate the role of epithelial cell IL-12 family members in allograft dysfunction associated with and without viral infection. METHODS Murine and human IL-12 family members were characterized and manipulated in allografts and then correlated with epithelial cell injury, immune cell accumulation, and collagen deposition. RESULTS In a mouse model of lung transplantation, concurrent viral infection and allogeneic transplantation increased epithelial injury and this was followed by exaggerated accumulation of macrophages and collagen deposition. This virus-driven allograft dysfunction was associated with an epithelial innate response manifested by a synergistic increase in the production of the macrophage chemoattractant IL-12 p80 (p80), but not IL-12 or IL-23. Blockade or overexpression of donor epithelial p80 resulted in a corresponding abrogation or enhancement of macrophage accumulation and allograft dysfunction. We extended these findings to human recipients with viral infection and transplant bronchitis and again observed excessive epithelial p80 expression that correlated with increased macrophage accumulation. CONCLUSIONS These experiments support a role for an enhanced epithelial innate response as a central process in allograft dysfunction and identify the macrophage chemoattractant p80 as an innate epithelial effector of disease progression.
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Affiliation(s)
- Cassandra L Mikols
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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