Henke J A, Golden J A, Yelin E H, Keith F A, Blanc P D
Department of Medicine, University of California San Francisco, USA.
Chest. 1999 Feb;115(2):403-9. doi: 10.1378/chest.115.2.403.
To evaluate whether findings from surveillance bronchoscopy predict survival following lung transplantation.
Retrospective review and analysis of 498 bronchoscopies with transbronchial biopsy (TBB) and BAL performed in 34 patients after lung transplantation.
University-based, tertiary referral medical center.
Thirty-four patients after lung transplantation. The mean age at transplantation was 49+/-9 years; 20 (59%) were female. Twenty-four (71%) underwent single and 10 (29%) underwent bilateral lung transplantation. The most common pretransplantation diagnostic groups were emphysema/COPD without concomitant alpha1-antiprotease deficiency (n = 13) and other obstructive disease processes (n = 10).
Over follow-up, subjects underwent multiple bronchoscopies with TBB and BAL. The median number per subject was 15 (25 to 75% range 13 to 17).
We calculated the overall median BAL WBCs and median percent neutrophils (polymorphonuclear leukocytes [PMNs]) among all of the BALs performed for each subject. We then calculated the mean +/- SD of those median values. We used Cox proportionate hazards to assess mortality risk. The median overall follow-up observation period for the cohort was 560 days. There were 11 deaths during this period. Twenty-four subjects (71%) had acute rejection (AR) grades 2 to 4 (mild to severe), and nine (27%) had obliterative bronchiolitis (OB) diagnosed by TBB at any point. The mean value for BAL WBCs was 366+/-145 x 10(3) per milliliter; for percentage PMNs, the mean was 7+/-10%. Adjusting for age, gender, single vs bilateral lung transplantation, pretransplantation diagnostic group, presence of AR, presence of OB, BAL WBC concentration, and lymphocyte CD4/CD8 ratio, PMN percent was a significant predictor of mortality (p = 0.02).
Ongoing inflammation manifested by an increased percentage PMNs over repeated bronchoscopies predicts mortality following lung transplantation. Biopsy data alone may be insufficient to identify posttransplantation patients at risk of poor outcome.
评估监测性支气管镜检查结果能否预测肺移植后的生存率。
对34例肺移植患者进行的498次经支气管活检（TBB）和支气管肺泡灌洗（BAL）的支气管镜检查进行回顾性分析。
大学附属三级转诊医疗中心。
34例肺移植患者。移植时的平均年龄为49±9岁；20例（59%）为女性。24例（71%）接受单肺移植，10例（29%）接受双肺移植。最常见的移植前诊断组为无α1抗胰蛋白酶缺乏的肺气肿/慢性阻塞性肺疾病（COPD）（n = 13）和其他阻塞性疾病（n = 10）。
在随访期间，受试者接受多次TBB和BAL支气管镜检查。每位受试者的检查次数中位数为15次（四分位间距为13至17次）。
我们计算了每位受试者所有BAL检查中总的BAL白细胞中位数和中性粒细胞百分比中位数（多形核白细胞[PMN]）。然后计算这些中位数的平均值±标准差。我们使用Cox比例风险模型评估死亡风险。该队列的中位总随访观察期为560天。在此期间有11例死亡。24例受试者（71%）发生2至4级急性排斥反应（AR）（轻度至重度），9例（27%）在任何时间点经TBB诊断为闭塞性细支气管炎（OB）。BAL白细胞的平均值为每毫升366±145×10³；PMN百分比的平均值为7±10%。校正年龄、性别、单肺与双肺移植、移植前诊断组、AR的存在、OB的存在、BAL白细胞浓度和淋巴细胞CD4/CD8比值后，PMN百分比是死亡的显著预测因素（p = 0.02）。
在重复支气管镜检查中PMN百分比增加所表现出的持续炎症可预测肺移植后的死亡率。仅活检数据可能不足以识别移植后预后不良风险的患者。
