Valentine Vincent G, Taylor David E, Dhillon Gundeep S, Knower Mark T, McFadden P Michael, Fuchs Denise M, Kantrow Stephen P
Department of Multi-Organ Transplant, Ochsner Medical Institutions, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA.
J Heart Lung Transplant. 2002 Mar;21(3):319-26. doi: 10.1016/s1053-2498(01)00389-8.
No current evidence demonstrates improved survival or decreased rate of bronchiolitis obliterans syndrome (BOS) despite regularly scheduled fiberoptic bronchoscopy (FOB) with transbronchial biopsy and bronchoalveolar lavage (TBB/BAL) after lung transplantation. Reduced lung function detected with spirometry or oximetry in symptomatic and asymptomatic lung allograft recipients (LARs) may be a more appropriate indication for bronchoscopic sampling.
Clinically indicated TBB/BAL without routine invasive surveillance sampling of the transplanted lung does not decrease survival or increase the rate of BOS in LARs.
We reviewed 91 consecutive LARs transplanted at Ochsner Clinic between January 1995 and December 1999. Clinical indications for FOB with TBB/BAL include 10% decline in forced expiratory volume in 1 second below baseline; 20% decrease in forced expiratory flow rate between 25% and 75% of the forced vital capacity; or unexplained respiratory symptoms, signs, or fever. Along with demographic and clinical data, 1-year and 3-year survival rates for these 91 LARs were compared with 5,430 LARs from the International Society for Heart and Lung Transplantation (ISHLT) Registry transplanted during the same 60-month period. Ten of the 91 patients did not survive to hospital discharge after transplantation. We divided the remaining 81 LARs into 2 subsets: Group A patients (n = 43) underwent zero to 1 TBB/BAL and Group B patients (n = 38) required more than 1 procedure. Demographic data, rejection, infection, and incidence of BOS were compared between groups.
The 1-year and 3-year survival rates in the Ochsner LAR cohort were 85% and 73%, respectively, vs 72% and 57% in the ISHLT cohort p < 0.01. The relative risks of death in the Ochsner group at 1- and 3-years were 0.56 (0.35-0.91) and 0.66 (0.48-0.92), respectively, p < 0.05. The median (range) follow-up was 910 days (60-1,886) for Group A and 961 days (105-1,883) for Group B, p = not significant. We observed twice as many patients with cystic fibrosis and twice as many pneumonia episodes in Group B. The rate of acute rejection in each group was not statistically different. The cumulative incidence of BOS was increased in Group B at 1 year and at 3 years (5% and 56%) when compared with Group A (3% and 13%), p < 0.01.
Based on the findings from this observational, single-institution study, clinically indicated TBB/BAL without routine surveillance sampling of the lung allograft is unlikely to pose greater risk than does regularly scheduled bronchoscopy after lung transplantation.
目前尚无证据表明，肺移植术后定期进行纤维支气管镜检查（FOB）并经支气管活检及支气管肺泡灌洗（TBB/BAL）能提高生存率或降低闭塞性细支气管炎综合征（BOS）的发生率。对于有症状和无症状的肺移植受者（LARs），通过肺活量测定法或血氧测定法检测到的肺功能下降可能是更合适的支气管镜检查取样指征。
对于LARs，临床指征性TBB/BAL且不对移植肺进行常规侵入性监测取样不会降低生存率或增加BOS发生率。
我们回顾了1995年1月至1999年12月在奥施纳诊所连续接受移植的91例LARs。进行TBB/BAL的FOB的临床指征包括1秒用力呼气量较基线下降10%；用力肺活量25%至75%之间的用力呼气流速下降20%；或不明原因的呼吸道症状、体征或发热。除人口统计学和临床数据外，将这91例LARs的1年和3年生存率与同期国际心肺移植协会（ISHLT）登记处的5430例LARs进行比较。91例患者中有10例移植后未存活至出院。我们将其余81例LARs分为2个亚组：A组患者（n = 43）接受0至1次TBB/BAL，B组患者（n = 38）需要进行1次以上操作。比较两组的人口统计学数据、排斥反应、感染和BOS发生率。
奥施纳LAR队列的1年和3年生存率分别为85%和73%，而ISHLT队列分别为72%和57%，p < 0.01。奥施纳组1年和3年的相对死亡风险分别为0.56（0.35 - 0.91）和0.66（0.48 - 0.92），p < 0.05。A组的中位（范围）随访时间为910天（60 - 1886天），B组为961天（105 - 1883天），p = 无显著差异。我们观察到B组中囊性纤维化患者数量是A组的两倍，肺炎发作次数也是A组的两倍。每组的急性排斥反应发生率无统计学差异。与A组（3%和13%）相比，B组1年和3年的BOS累积发生率增加（5%和56%），p < 0.01。
基于这项单机构观察性研究的结果，对于LARs，临床指征性TBB/BAL且不对移植肺进行常规监测取样带来的风险可能不会高于肺移植后定期进行支气管镜检查。
