Surveillance Bronchoscopy in Lung Transplant Recipients: Risk versus Benefit

McWilliams, Tanya; Williams, Trevor; Whitford, Helen; Snell, Gregory I

doi:10.1016/j.healun.2008.08.004

Cited by 95 publications

(75 citation statements)

References 28 publications

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“…However, in the context of data suggesting that detection of silent acute rejection may not affect long-term outcomes (22)(23)(24), the use of surveillance bronchoscopy in otherwise asymptomatic patients may be to identify those at increased risk for BOS (25). A strategy that avoids transbronchial biopsy in surveillance of asymptomatic patients could reduce risk of procedural complications (26,27). Our finding that large-airway lymphocytic bronchitis more accurately identifies patients at risk for BOS than pathology results of transbronchial biopsies supports a strategy using only lower-risk endobronchial biopsies for surveillance.…”

Section: Discussionmentioning

confidence: 99%

Association of Large-Airway Lymphocytic Bronchitis with Bronchiolitis Obliterans Syndrome

Greenland

Jones²,

Hays³

et al. 2013

Am J Respir Crit Care Med

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Rationale: Lung transplantation offers great promise for otherwise terminal lung diseases, but the development of bronchiolitis obliterans syndrome (BOS) continues to limit survival. Although acute rejection and lymphocytic bronchiolitis have been identified as risk factors for the development of BOS, it is unclear whether largeairway lymphocytic inflammation conveys the same risk. Objectives: We evaluated lymphocytic bronchitis on endobronchial biopsies as a risk factor for BOS and mortality. Methods: Endobronchial biopsies were collected and graded during surveillance after lung transplantation. We assessed samples with negative cultures collected in the first 90 days from 298 subjects and compared large-airway lymphocytic bronchitis assessed by a 0-2 "E-score" and with standard A and BR pathology scores for acute rejection and small-airway lymphocytic bronchiolitis, respectively. Measurements and Main Results: We found surprisingly little association between large-and small-airway lymphocytic inflammation scores from a given bronchoscopy. Endobronchial lymphocytic bronchitis was more prevalent in subjects in BOS stage 0p and BOS stages 1-3 at the time of biopsy. Within 90 days after transplantation, increasing maximum E-score was associated with greater risk of BOS (adjusted hazard ratio, 1.76; 95% confidence interval, 1.11-2.78; P ¼ 0.02) and in this analysis 90-day maximum E-scores were the only score type predictive of BOS (P , 0.01). Conclusions: These results support a multicenter study to evaluate endoscopic biopsies for the identification of patients at increased risk for BOS. The association of endobronchial lymphocytic inflammation and BOS may have mechanistic implications.Keywords: bronchiolitis obliterans; graft rejection; bronchoscopy; lung transplantation Lung transplantation can offer improved quality of life and survival from otherwise terminal lung diseases. However, the development of chronic rejection, manifested as bronchiolitis obliterans syndrome (BOS), is a major barrier to long-term patient survival (1). BOS can cause death from graft failure and can occur despite potent immunosuppression (2, 3). One risk factor for BOS is symptomatic acute rejection (4). When confirmed by transbronchial biopsy, acute rejection generally is treated with additional immunosuppressive medications (5). Most lung transplantation centers also use surveillance bronchoscopy to identify otherwise silent episodes of acute rejection (6), presuming that untreated acute rejection increases the risk of BOS (7,8).Previous studies revealed that small-airways lymphocytic bronchiolitis in transbronchial biopsy specimens also is associated with increased risk of BOS (9). Endobronchial biopsies have been evaluated in lung transplant recipients, in whom acute rejection and current BOS were associated with largeairway lymphocytosis (10). This lymphocytosis is predominantly CD4 1 and CD45 1 (10). Work from the present laboratory showed differential expression of gene transcripts in patients with large-airway, but not small-ai...

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Section: Discussionmentioning

confidence: 99%

Association of Large-Airway Lymphocytic Bronchitis with Bronchiolitis Obliterans Syndrome

Greenland

Jones²,

Hays³

et al. 2013

Am J Respir Crit Care Med

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“…A carefully controlled sampling process (13) in combination with standardized sample fractionation and MALDI-TOF subproteome profile spectra provides the basis for a statistical model constructed from a robust marker panel (14,15). In addition to markers that are of putative clinical relevance, other newly identified BALF constituents might add to the basic understanding of transplant injury and OB pathogenesis.…”

Section: Discussionmentioning

confidence: 99%

Proteomic Bronchiolitis Obliterans Syndrome Risk Monitoring in Lung Transplant Recipients

Wolf¹,

Oumeraci²,

Gottlieb³

et al. 2011

Transplantation

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Monitoring the bronchoalveolar lavage fluid levels of seven polypeptides detected by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry allows a reliable prediction of early BOS using a Random Forest decision tree-based classifier model. The high accuracy of this robust model and its synergistic potential in combination with established forced expiratory volume-based diagnostics could make it an effective tool to supplement the current diagnostic regime after multicentric validation.

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“…The importance of noninvasive graft monitoring is further emphasized as subclinical rejection may occur: these cases can exclusively be detected with (invasive) surveillance or protocol biopsies (13)(14)(15)(16)(17). Currently, to our knowledge, AlloMap is the only commercially available noninvasive organ transplant monitoring test (18).…”

Section: Introductionmentioning

confidence: 99%