Chronic Rejection after Lung Transplantation

Song Yee Kim

doi:10.4285/jkstn.2016.30.3.120

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Kim: Chronic Rejection after Lung Transplantation

Review Article

J Korean Soc Transplant 2016;30(3):120-124.

Published online: 19 January 2016

DOI: https://doi.org/10.4285/jkstn.2016.30.3.120

Chronic Rejection after Lung Transplantation

Song Yee Kim, M.D.

Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea

Corresponding author: Song Yee Kim Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: 82-2-2228-1940, Fax: 82-2-393-6884 E-mail: dobie@yuhs.ac

Received 9 September 2016 Accepted 9 September 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A new classification system for chronic rejection in lung transplantation was recently proposed. Chronic lung allograft dysfunction (CLAD) is regarded as chronic rejection after excluding other causes of allograft dysfunction. CLAD is divided into obstructive CLAD (bronchiolitis obliterans syndrome) and restrictive CLAD (restrictive allograft syndrome). In this review, we will review the latest concepts and current controversies regarding the new CLAD terminology, diagnostic approach, risk factors and possible treatment options.

Keywords: Lung transplantation, Graft rejection, Bronchiolitis obliterans

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Table 1.

Confounding factors leading to FEV₁ decline other than chronic rejection

Allograft-related

Persistent acute rejection

ARAD

Infection/Colonization

Anastomotic stricture

Disease recurrence

Follicular bronchiolitis

Extra-allograft

Pleural disease

Diaphragm dysfunction

Native lung hyperinflation

Otder causes

Abbreviations: ARAD, azithromycin-responsive allograft dysfunction. Adapted from Fig. 1 of reference [8].

Table 2.

Original and proposed classification of BOS

	Original classification		Current proposition
BOS 0	FEV₁ 80% or more of baseline	BOS 0	FEV₁＞90% of baseline and FEF_25∼75% of baseline
		BOS 0-p	FEV₁ 81% to 90% of baseline and/or FEF_25∼75% ＜75% of baseline
BOS 1	FEV₁ 66% to 80% of baseline	BOS 1	FEV₁ 66% to 80% of baseline
BOS 2	FEV₁ 51% to 65% of baseline	BOS 2	FEV₁ 51% to 65% of baseline
BOS 3	FEV₁ 50% or less of baseline	BOS 3	FEV₁ 50% or less of baseline

Abbreviations: BOS, bronchiolitis obliterans syndrome; FEF_25∼75%, mild-expiratory flow rate; FEV₁, forced expiratory volume in 1 second. Adapted from Table 1 of reference [10].

Table 3.

Risk factors for BOS

Primary graft dysfunction

Acute cellular rejection

Lymphocytic bronchiolitis

Antibody-mediated rejection (de novo donor-specific anti-human leukocyte antigen antibodies)

Gastroesophageal reflux and microaspiration

Introduction/Colonization

Persistent neutrophil reflux and sequestration

Autoimmunity (e.g. collagen V sensitization)

Air pollution

Genetic factors

Abbreviations: BOS, bronchiolitis obliterans syndrome. Adapted from Table 1 of reference [11].

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