Journal List > J Korean Soc Transplant > v.30(3) > 1034486

Kim: Chronic Rejection after Lung Transplantation

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.

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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 FEF25∼75% of baseline
    BOS 0-p FEV1 81% to 90% of baseline and/or FEF25∼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; FEF25∼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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