Are multiple immunopathogenetic events occurring during the development of obliterative bronchiolitis and acute rejection?

The primed lymphocyte test (PLT) has been used to detect donor antigen-specific reactivity of bronchoalveolar lavage (BAL) lymphocytes associated with acute lung rejection and obliterative bronchiolitis (OB). To identify more precisely the immunopathogenetic events related to these processes, we have determined the PLT alloreactivity of 162 BAL specimens from 40 recipients as being directed against individual class I or class II antigens. We used selected homozygous typing cells representing the specific HLA class I and II antigens expressed by the recipient and donor cells. Our previous studies demonstrated a predominant CD8+ cell population mediating class I donor antigen-specific reactivity, correlating with OB in 3 out of 3 recipients tested, and a predominant CD4+ cell population mediating class II donor antigen-specific reactivity, correlating with acute rejection episodes in 13 out of 15 recipients tested. The obstructive airway disease OB, which is frequently fatal, is identified histologically by the presence of small airway inflammation and fibrosis of the lamina propria and lumen, and is characterized clinically by rapidly progressive airflow obstruction. However, a subgroup of patients with histologically proven OB demonstrates stabilization or only minimal progression of airflow limitation after augmentation of their immunosuppressive regimen, usually with high-dose methylprednisolone. To further characterize this subgroup, we tested the BAL-derived lymphocytes from 4 of these patients and observed PLT reactivity that correlated with the class II antigens of the donor, in contrast to the predominant donor class I antigen-specific PLT reactivity of patients with progressive OB. The distinct patterns of PLT reactivity observed for the BAL-derived lymphocytes from patients with the progressive versus the less progressive form of OB suggest that more than one immune process or perhaps different cell targets are involved. Alternatively, these clinical and in vitro findings may represent different stages of the same disease process. Taken together, these results suggest that distinct immunopathogenetic events may be occurring during acute lung rejection and OB.