Baz M A, Layish D T, Govert J A, Howell D N, Lawrence C M, Davis R D, Tapson V F
Department of Medicine, Duke University Medical Center, Durham, NC, USA.
Chest. 1996 Jul;110(1):84-8. doi: 10.1378/chest.110.1.84.
Lung transplantation has become an acceptable therapeutic option for end-stage pulmonary diseases. The most common causes of long-term mortality after transplantation are infections and obliterative bronchiolitis (OB). While acute rejection has been shown to be associated with an increased risk of development of OB, cytomegalovirus (CMV) pneumonitis is more controversial as a risk factor for OB. Surveillance bronchoscopies are therefore advocated as a method of detecting silent episodes of CMV pneumonitis or acute rejection. We performed 226 bronchoscopies in 43 lung transplant recipients over 34 months. One hundred fifty-seven of the 226 bronchoscopies were performed according to a surveillance protocol. Acute rejection was diagnosed if lung histologic study revealed grade 2 to 4 rejection or if prompt reversal of clinical deterioration occurred after initiation of pulse steroid therapy. CMV pneumonitis was diagnosed when transbronchial biopsy histologic specimens revealed evidence of CMV inclusion bodies, or when CMV was recovered on BAL fluid in the presence of allograft deterioration. The proportion of patients who were free from any episode of acute rejection or CMV pneumonitis after transplantation was determined by Kaplan-Meier analysis. Twenty-one percent of our transplant recipients were free from acute rejection or CMV pneumonitis after a mean follow-up of 13 months. All patients who had acute rejection or CMV pneumonitis had the initial episode in the first 4 months after transplantation. Patients free of acute rejection or CMV pneumonitis 4 months after transplantation continued to be event free for the duration of follow-up. Our data suggest that surveillance bronchoscopy can be aborted in patients who are free from acute rejection or CMV pneumonitis by 4 months after transplantation. The role of surveillance bronchoscopy in decreasing the incidence of OB or improving survival can be determined only by future randomized prospective trials.
肺移植已成为终末期肺部疾病可接受的治疗选择。移植后长期死亡的最常见原因是感染和闭塞性细支气管炎（OB）。虽然急性排斥反应已被证明与OB发生风险增加有关，但巨细胞病毒（CMV）肺炎作为OB的危险因素更具争议性。因此，提倡通过监测支气管镜检查来检测CMV肺炎或急性排斥反应的无症状发作。我们在34个月内对43例肺移植受者进行了226次支气管镜检查。226次支气管镜检查中有157次是按照监测方案进行的。如果肺组织学研究显示2至4级排斥反应，或者在开始脉冲类固醇治疗后临床病情迅速好转，则诊断为急性排斥反应。当经支气管活检组织学标本显示有CMV包涵体证据，或在同种异体移植恶化的情况下BAL液中检测到CMV时，诊断为CMV肺炎。通过Kaplan-Meier分析确定移植后无急性排斥反应或CMV肺炎发作的患者比例。平均随访13个月后，我们21%的移植受者无急性排斥反应或CMV肺炎。所有发生急性排斥反应或CMV肺炎的患者在移植后的前4个月出现首次发作。移植后4个月无急性排斥反应或CMV肺炎的患者在随访期间持续无事件发生。我们的数据表明，对于移植后4个月无急性排斥反应或CMV肺炎的患者，可以停止监测支气管镜检查。监测支气管镜检查在降低OB发病率或提高生存率方面的作用只能通过未来的随机前瞻性试验来确定。
