Original Articles
Causes of allograft dysfunction after single lung transplantation for emphysema: extrinsic restriction versus intrinsic obstruction

https://doi.org/10.1016/S1053-2498(99)00067-4Get rights and content

Abstract

Background: A subset of patients with emphysema who have undergone single lung transplantation (SLT) may subsequently present with dyspnea, worsening airways obstruction, hypoxemia, and progressive chronic native lung hyperinflation. The leading cause of late allograft dysfunction is bronchiolitis obliterans syndrome (BOS). However, extrinsic restriction manifests with a similar clinical presentation and is an additional mechanism to consider. We describe the use of the inspiratory lung resistance (RLi) to distinguish a decline in respiratory status due predominantly to either extrinsic restriction or BOS.

Methods

We studied five patients who underwent SLT for emphysema between 1992 and 1995, in whom the diagnoses of BOS and extrinsic restriction were subsequently entertained. Forced expiratory volume in 1 second (FEV1), RLi, static lung compliance, elastic recoil pressure at total lung capacity (TLC), and the slope of the maximum flow static recoil (MFSR) plot were measured.

Results

All patients had severe airflow obstruction, with mean FEV1 0.98 ± 0.24 liter (26 ± 5% predicted), elevated static lung compliance, reduced elastic recoil pressure at TLC, and reduced slope of the MFSR plot. Three patients had “low” RLi (9.3–12.8 cm H2O/L/sec). Obstruction was attributed predominantly to extrinsic restriction. These patients underwent lung volume reduction surgery (LVRS) on the native lung; improvements in pulmonary mechanics were observed at 6 months. In contrast, two patients had markedly elevated RLi (17.3 and 17.4 cm H2O/L/sec). Obstruction was attributed predominantly to intrinsic airway disease from BOS that was subsequently documented at autopsy.

Conclusions

The RLi appears to be a useful adjunct to the clinical history in distinguishing a decline in respiratory status due predominantly to either BOS or extrinsic restriction in patients who have undergone SLT for emphysema. Determination of the mechanism of allograft dysfunction may allow the selection of an appropriate subset of patients who would benefit from LVRS.

Section snippets

Patients and methods

Of the 34 patients who underwent SLT for emphysema between 1990 and 1995, we studied 5 patients who subsequently presented with a clinical picture suggesting either BOS or extrinsic restriction (Table I). No patient had α1-antitrypsin deficiency. Three patients underwent left SLT, and two patients received a right-sided allograft. Long-term immunosuppression was maintained by a regimen of cyclosporine, azathioprine, and prednisone. Time from SLT to presentation ranged from 18 to 36 months.

Results

All five patients had dyspnea on exertion, hypoxemia, and severe airways obstruction (see Table I). Representative chest CT scans shown in FIGURE 1, FIGURE 2 demonstrated progressive native lung hyperinflation and volume loss of the allograft at the time of study compared to the immediate post -transplantation period. The patients had no evidence of active bacterial or cytomegaloviral pneumonia. There was no evidence of acute rejection on transbronchial biopsies, and all patients had patent

Discussion

In these five patients, the RLi appears to be a useful adjunct to the clinical history in distinguishing allograft dysfunction due predominantly to extrinsic restriction from that due to BOS in patients having undergone SLT for emphysema. Determination of the mechanism of allograft dysfunction after SLT for emphysema may allow selection of an appropriate subset of patients who would benefit from LVRS.

At presentation, the elevated RLi in all five patients may have been due to both severe

Acknowledgements

The authors thank Mary J. Connolly, Jennifer D. Rodenhouse, and Allison Smith for their assistance.

References (16)

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Grant Support: This work was supported in part by NIH/NHLBI grants HL52586 and HL07633.

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