Verleden S E, Todd J L, Sato M, Palmer S M, Martinu T, Pavlisko E N, Vos R, Neyrinck A, Van Raemdonck D, Saito T, Oishi H, Keshavjee S, Greer M, Warnecke G, Gottlieb J, Haverich A
Lung Transplant Unit, University Hospitals Leuven and Department of Experimental Medicine, KULeuven, Leuven, Belgium.
Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC.
Am J Transplant. 2015 Aug;15(8):2223-30. doi: 10.1111/ajt.13281. Epub 2015 Apr 30.
Chronic lung allograft dysfunction (CLAD) remains a major problem after lung transplantation with no definitive treatment except redo lung transplantation (re-LTx) in selected candidates. However, CLAD is not a homogeneous entity and different phenotypes exist. Therefore, we aimed to evaluate the effect of CLAD phenotypes on survival after re-LTx for CLAD. Patients who underwent re-LTx for respiratory failure secondary to CLAD in four LTx centers between 2003 and 2013 were included in this retrospective analysis. Bronchiolitis obliterans syndrome (BOS) and restrictive CLAD (rCLAD) were distinguished using pulmonary function, radiology and explant lung histopathology. Patient variables pre- and post-re-LTx were collected and analyzed. A total of 143 patients underwent re-LTx for CLAD resulting in 94 BOS (66%) and 49 rCLAD (34%) patients. Unadjusted and adjusted survival after re-LTx for rCLAD was worse compared to BOS (HR = 2.60, 1.59-4.24; p < 0.0001 and HR = 2.61, 1.51-4.51; p = 0.0006, respectively). Patients waiting at home prior to re-LTx experienced better survival compared to hospitalized patients (HR 0.40; 0.23-0.72; p = 0.0022). Patients with rCLAD redeveloped CLAD earlier and were more likely to redevelop rCLAD. Survival after re-LTx for rCLAD is worse compared to BOS. Consequently, re-LTx for rCLAD should be critically discussed, particularly when additional peri-operative risk factors are present.
慢性肺移植功能障碍（CLAD）仍是肺移植后的一个主要问题，除了对选定的候选者进行再次肺移植（re-LTx）外，尚无确切的治疗方法。然而，CLAD并非单一的实体，而是存在不同的表型。因此，我们旨在评估CLAD表型对因CLAD接受再次肺移植后的生存影响。本回顾性分析纳入了2003年至2013年间在四个肺移植中心因CLAD继发呼吸衰竭而接受再次肺移植的患者。使用肺功能、放射学和移植肺组织病理学来区分闭塞性细支气管炎综合征（BOS）和限制性CLAD（rCLAD）。收集并分析再次肺移植前后的患者变量。共有143例患者因CLAD接受了再次肺移植，其中94例为BOS（66%），49例为rCLAD（34%）。与BOS相比，rCLAD再次肺移植后的未调整和调整后生存率更差（风险比分别为2.60，1.59 - 4.24；p < 0.0001和2.61，1.51 - 4.51；p = 0.0006）。与住院患者相比，再次肺移植前在家等待的患者生存率更高（风险比0.40；0.23 - 0.72；p = 0.0022）。rCLAD患者更早复发CLAD，且更有可能再次发展为rCLAD。与BOS相比，rCLAD再次肺移植后的生存率更差。因此，对于rCLAD的再次肺移植应进行严格讨论，尤其是当存在额外的围手术期风险因素时。
