Chest
Volume 102, Issue 4, October 1992, Pages 1049-1054
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The Role of Transbronchial Lung Biopsy in the Treatment of Lung Transplant Recipients: An Analysis of 200 Consecutive Procedures

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Study Objective: The purposes of this study were as follows: (1) to establish the positivity rate and complication rate of transbronchial lung biopsies in the treatment of lung transplant recipients; (2) to determine the sensitivity of transbronchial lung biopsy specimens for the diagnosis of clinically suspected acute rejection and cytomegalovirus pneumonia; and (3) to examine the results of surveillance transbronchial lung biopsies in clinically and physiologically stable recipients.

Design: Retrospective review and analysis of 203 consecutive procedures.

Setting: Washington University Lung Transplantation Program, Washington University School of Medicine and Barnes Hospital, St. Louis, Mo.

Patients: Fifty-five lung transplant recipients.

Interventions: Biopsies were done with 2-mm fenestrated forceps using fluoroscopic guidance. Two hundred three bronchoscopies with transbronchial lung biopsy were performed for clinical indications (n = 88), routine surveillance (n = 90), or follow-up of a previous biopsy (n = 25). Biopsy specimens showing acute allograft rejection were classified according to the scheme recommended by the Lung Rejection Study Group.

Measurements and Results: The positivity rate and complication rate were determined for the procedures. In procedures performed for clinical indications, the sensitivity for the diagnosis of acute rejection and cytomegalovirus pneumonia was calculated by a decision-to-treat analysis. A specific histologic diagnosis was detected in 69 percent of the clinical procedures, 57 percent of the surveillance procedures, and 64 percent of the follow-up procedures. For clinical indications, the sensitivity of transbronchial lung biopsy was 72 percent for the diagnosis of acute rejection and 91 percent for the diagnosis of cytomegalovirus pneumonia. Surveillance biopsy specimens often showed clinically inapparent rejection or cytomegalovirus pneumonia. The overall complication rate was 8.9 percent; none of the complications were life threatening.

Conclusions: Transbronchial lung biopsy is a useful and safe procedure in the treatment of lung transplant recipients. When performed for clinical indications, the procedure proved to be sensitive for the diagnosis of acute rejection and cytomegalovirus pneumonia. When performed for surveillance in clinically and physiologically stable recipients, the incidence of rejection and cytomegalovirus pneumonia was unexpectedly high; the potential clinical implications of these findings will require further study.

Section snippets

Design

This study was a retrospective review and analysis of 203 bronchoscopies with transbronchial lung biopsies performed in 55 lung transplant recipients.

Patients

Between July 1, 1988 and February 13, 1991, 69 lung transplants were performed in 66 recipients. Three patients had retransplantations, two for early graft failure and one for late chronic rejection. Potential recipients were selected according to predetermined criteria.9 Single (SLT), double (DLT), and bilateral (BLT) lung transplants were

RESULTS

Two hundred three procedures were performed in 55 recipients. All except six recipients underwent more than one procedure, and the average number of procedures per recipient was 3.7. The number of procedures for each indication is presented in Table 3. Eighty-eight procedures were performed in 42 recipients for a clinical indication, 90 procedures were performed in 43 recipients for surveillance, and 25 procedures were performed in 16 recipients for follow-up.

The results of the procedures are

DISCUSSION

During the last several years, lung transplant activity has expanded rapidly, and in the United States, the annual number of lung transplants now substantially exceeds the number of heart-lung transplants. After both heart-lung and lung transplantation, early deaths have been primarily related to perioperative complications and infection, and late morbidity and mortality have been associated with both infection and rejection.1 Because clinical criteria for the diagnosis of rejection, such as

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