Clinical lung and heart/lung transplantation
Bronchiolitis obliterans syndrome in single lung transplant recipients—patients with emphysema versus patients with idiopathic pulmonary fibrosis

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Abstract

Bronchiolitis obliterans syndrome (BOS) after lung transplantation is a disease of small airways that is currently graded according to a decline in forced expiratory volume in 1 second (FEV1) even in single lung transplant recipients in whom native diseased lung may influence lung physiology. The aim of this study was to evaluate the comparative changes in lung function and survival following the onset of BOS in patients with emphysema and patients with idiopathic pulmonary fibrosis (IPF) who have undergone single lung transplantation. We analyzed data from 31 single lung transplant recipients with emphysema and 25 with IPF who were at risk of BOS. There was no difference in the incidence of BOS between the 2 groups (10 patients with emphysema and 6 patients with IPF), but after the onset of BOS the patients with emphysema had a significantly greater median survival (18 months vs 8 months) despite a poorer mean FEV1 (1.26 liter, 45% predicted vs 2.11 liter, 67% predicted) compared with the IPF group (p < 0.05) and this difference in lung function persisted at death (0.8 liter, 30% predicted vs 1.65 liter, 51% predicted) (p < 0.05). In summary the native lung physiology appears to influence lung function and therefore survival, and this may indicate that the classification of BOS should include disease-specific characteristics.

Introduction

Single lung transplantation (SLT) is a surgical treatment for the management of end-stage lung disease, most commonly performed in patients with emphysema and idiopathic pulmonary fibrosis (IPF). The functional results in these patients following transplantation are excellent.1

However, the lung allograft is exposed to multiple injuries including donor injury, ischemia/reperfusion, acute rejection, or infection (bacterial, fungal, or cytomegalovirus). This leads to the development of bronchiolitis obliterans syndrome (BOS).2 The term bronchiolitis obliterans is used synonymously with chronic graft failure or chronic rejection and is the major limiting factor in the long-term survival of lung transplant recipients. Histologically obliterative bronchiolitis (OB) is characterized by fibrosis and obliteration of terminal bronchioles.

A clinical classification of patients with graft failure based on changes in forced expiratory volume in 1 second (FEV1) was introduced in 1993 to standardize nomenclature and to facilitate evaluation of the outcome of patients following transplantation. FEV1 was applied despite the fact that obliterative bronchiolitis is a small airways disease. Of particular importance in this classification was that graft failure was recognized to be a syndrome (BOS), not requiring histologic confirmation of obliterative bronchiolitis. The BOS classification was originally intended for use in double lung and heart-lung transplant recipients, but single lung transplant recipients (SLTRs) were included also despite concern that the native lung may influence FEV1.3

Survival data from the International Society of Heart and Lung Transplantation (ISHLT) have emphasized that patients who undergo SLT for emphysema have a significantly better survival than those who undergo SLT for IPF.4, 5 The reason for this is unclear. However, it has been hypothesized that host factors, particularly a predilection to mounting a fibroproliferative response to injury, may confer a survival disadvantage to patients with IPF.6

This study was undertaken to evaluate the difference in survival and lung function between IPF and patients with emphysema following the development of BOS.

Section snippets

Methods

Over a 9-year period from 1990 to 1999 this center performed 75 SLTs.

Total SLT population

The mean age at transplantation of the SLTR population (n = 56) was 53 years (range, 44–61 years) in the emphysema group (n = 31) and 52 years (range, 33–63 years) in the IPF group (n = 25).

There was no significant difference in body mass index (BMI), with a mean of 22.5 kg/m2 (range, 17–35 kg/m2) in the emphysema group compared with 24.6 kg/kg/m2 (range, 17–35 kg/m2) in the IPF group.

Lung function pre-operatively and post-operatively in each group is shown in Table I. Following

Discussion

This study highlights the survival pattern following the development of BOS in patients with emphysema vs patients with IPF who have undergone SLT. Despite poorer absolute values of FEV1, emphysema patients with BOS have significantly better survival. This may argue for a disease-specific sub-classification of BOS.

The ISHLT grades BOS according to the percentage fall in FEV1 compared with the baseline (rather than absolute values) and the grade of BOS is presumed to represent the severity of

References (18)

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