Clinical lung and heart/lung transplantationBronchiolitis obliterans syndrome in single lung transplant recipients—patients with emphysema versus patients with idiopathic pulmonary fibrosis
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
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Cited by (23)
Relationship between FEV<inf>1</inf> decline and mortality in patients with bronchiolitis obliterans syndrome—a systematic literature review
2021, Respiratory MedicineCitation Excerpt :The mean age ranged between 33 and 56 years, with only one study [20] including patients aged between 5 and 19 years. Lung transplantation (single, bilateral or heart-lung) was the most common type of transplant (16 studies) [21,23–38], followed by allo-HSCT (7 studies) [5,20,22,39–43]. Underlying diseases that were most often mentioned were chronic obstructive pulmonary disease (COPD) [25,27,29,31–34,38], cystic fibrosis [23,25–27,31,33,36–38], alpha-1 antitrypsin deficiency [31,35,36], primary pulmonary hypertension [23,37], and bronchiectasis for lung transplantation [25,28], and different types of leukaemia for allo-HSCT [5].
Parameters of donor-recipient size mismatch and survival after bilateral lung transplantation
2012, Journal of Heart and Lung TransplantationCitation Excerpt :Further investigations should clarify whether the underlying diagnosis should or should not affect the lung size matching decision. Patients with IPF (the main indication in LAS Group D) were reported to develop bronchiolitis obliterans syndrome (BOS) earlier than COPD patients and had a shorter median survival after diagnosis.13 The reason for the observed earlier onset of BOS in IPF patients remains unclear.
Lung Transplant Outcomes in White and African American Recipients: Special Focus on Acute and Chronic Rejection
2009, Journal of Heart and Lung TransplantationCitation Excerpt :The first two factors have been identified in prior studies, but there is no good explanation for IPF as a protective factor for BOS.19,27 This likely reflects a detection bias, because the native lung in IPF contributes more to forced expiratory volume in 1 second (FEV1) than in other diagnoses, and the majority of our IPF patients were single-lung transplant recipients.28,29 Although our study is the largest to date to assess acute rejection and BOS in African American lung transplant recipients, it has several limitations.
Post-transplant Baseline FEV<inf>1</inf> and the Development of Bronchiolitis Obliterans Syndrome: An Important Confounder?
2007, Journal of Heart and Lung TransplantationLong-term Survival After Lung Transplantation Depends on Development and Severity of Bronchiolitis Obliterans Syndrome
2007, Journal of Heart and Lung TransplantationCitation Excerpt :Second, different sub-groups of patients may be more susceptible to death within each BOS grade, such as with respect to the recipient’s pre-transplant disease and type of transplant. Haider et al9 reported a similar risk of BOS in a study of SLTx recipients with idiopathic pulmonary fibrosis (IPF) vs those with chronic obstructive pulmonary disease (COPD); however, they also found that the hazard rate of death was much higher in patients with IPF than in patients with COPD with the same grade of BOS across all BOS grades. In addition, because DLTx patients usually have a higher pulmonary reserve, this group may differ from patients receiving SLTx with respect to freedom from BOS and BOS-free survival.10