Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Lung Transplant Program, Pharmacy Department, Brigham and Women's Hospital, Boston, Massachusetts.
J Heart Lung Transplant. 2018 Mar;37(3):340-348. doi: 10.1016/j.healun.2017.03.017. Epub 2017 Mar 24.
Survival after lung transplantation is limited by chronic lung allograft dysfunction (CLAD). Immunomodulatory therapies such as extracorporeal photopheresis (ECP) and alemtuzumab (AL) have been described for refractory CLAD, but comparative outcomes are not well defined.
We retrospectively reviewed spirometric values and clinical outcomes after therapy with ECP, AL, or no treatment (NT) in patients with CLAD who underwent transplant between January 2005 and December 2014. We used inverse probability-weighted regression adjustment (IPWRA) to adjust for potential confounders affecting treatment choice.
Of 267 patients, 31 received immunomodulatory therapies for CLAD, and 78 received NT. The slope of forced expiratory volume in 1 second (FEV) decline significantly improved after treatment with AL and with ECP compared with pre-treatment FEV slope; however, there was no significant change in slope of forced vital capacity (FVC). Comparison with NT was limited because of clinical differences in treatment groups. After IPWRA, we found no significant difference in mean difference of FEV slope (ml/month) when comparing treatment with NT, suggesting stabilization of lung function in the treatment group. We found no difference between the 2 immunomodulatory therapies 1, 3, and 6 months post-treatment (-49.9 [95% CI -581.8, +482.0], p = 0.85; +27.7 [95% CI -167.6, +223.0], p = 0.78; -9.6 [95% CI -167.5, +148.2], p = 0.91). We found no difference in mean FVC slope or differences between ECP and AL in infection rates or survival after treatment.
Immunomodulatory therapy for CLAD with ECP or AL was associated with a significant change in FEV slope post-treatment compared with pre-treatment slope, with minimal effect on FVC. There was no difference between the 2 therapies in their effect on pulmonary function.
肺移植后的存活率受到慢性肺移植物功能障碍（CLAD）的限制。已经描述了免疫调节疗法，如体外光化学疗法（ECP）和阿仑单抗（AL），用于治疗难治性 CLAD，但比较结果尚不清楚。
我们回顾性地审查了 2005 年 1 月至 2014 年 12 月期间接受肺移植的 CLAD 患者接受 ECP、AL 或无治疗（NT）治疗后的肺量计值和临床结果。我们使用逆概率加权回归调整（IPWRA）来调整影响治疗选择的潜在混杂因素。
在 267 名患者中，31 名患者因 CLAD 接受了免疫调节治疗，78 名患者接受了 NT。与治疗前的 FEV 斜率相比，AL 和 ECP 治疗后用力呼气量（FEV）下降的斜率明显改善；然而，用力肺活量（FVC）斜率没有明显变化。由于治疗组的临床差异，与 NT 相比，比较受到限制。经过 IPWRA 后，我们发现比较治疗与 NT 时，FEV 斜率的平均差异无统计学意义（ml/月），提示治疗组的肺功能稳定。我们发现两种免疫调节疗法在治疗后 1、3 和 6 个月时的差异无统计学意义（-49.9[95%CI-581.8，+482.0]，p=0.85；+27.7[95%CI-167.6，+223.0]，p=0.78；-9.6[95%CI-167.5，+148.2]，p=0.91）。我们没有发现 FVC 斜率的差异，也没有发现 ECP 和 AL 在治疗后的感染率或生存率方面的差异。
ECP 或 AL 治疗 CLAD 与治疗后 FEV 斜率与治疗前斜率相比有显著变化，对 FVC 影响最小。两种疗法在对肺功能的影响方面没有差异。
