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Objective: Lung transplantation has become accepted therapy for end-stage pulmonary disease. The objective of this study was to review a single-institution experience of adult lung transplants. Methods: We reviewed 1000 adult lung transplants that were performed at Washington University between July 1988 and January 2009. Results: Transplants were performed for emphysema (52%), cystic fibrosis (18.2%), pulmonary fibrosis (16.1%), and pulmonary vascular disease (7.2%). Overall recipient age was 48 ± 13 years with an increase from 43 ± 12 years (July 1988–November 1993) to 50 ± 14 years (June 2005–January 2009). Overall incidence of primary graft dysfunction was 22.1%. Hospital mortality was higher for patients who had primary graft dysfunction (primary graft dysfunction, 13.6%; no primary graft dysfunction, 4%; P < .001). Freedom from bronchiolitis obliterans syndrome was 84% at 1 year, 38.2% at 5 years, and 12.2% at 10 years. Survival at 1, 5, 10, and 15 years was 84%, 56.4%, 32.2%, and 17.8%, respectively. Five-year survival improved from 49.6% (July 1988–November 1993) to 62.1% (October 2001–June 2005). Primary graft dysfunction was associated with lower survival at 1, 5, and 10 years (primary graft dysfunction: 72.8%, 43.9%, and 18.7%, respectively; no primary graft dysfunction: 87.1%, 59.8%, and 35.7%, respectively, P < .001) and lower rates of freedom from bronchiolitis obliterans syndrome (primary graft dysfunction: 78%, 27.5%, and 8.5%, respectively; no primary graft dysfunction: 85.4%, 40.7%, and 13.1%, respectively, P = .007). Conclusions: Five-year survival has improved over the study period, but long-term outcomes are limited by bronchiolitis obliterans syndrome. Primary graft dysfunction is associated with higher rates of bronchiolitis obliterans syndrome and impaired short- and long-term survival. A better understanding of primary graft dysfunction and bronchiolitis obliterans syndrome is critical to improve outcomes. [Copyright &y& Elsevier]

Tocilizumab (TCZ), an IL-6 inhibitor, has shown promise in the treatment of donor-specific antibodies (DSA) and chronic antibody-mediated rejection (AMR) in renal transplant recipients. However, its use in lung transplantation has not been described. This retrospective case–control study compared AMR treatments containing TCZ in 9 bilateral lung transplant recipients to 18 patients treated for AMR without TCZ. Treatment with TCZ resulted in more clearance of DSA, lower recurrence of DSA, lower incidence of new DSA, and lower rates of graft failure when compared to those treated for AMR without TCZ. The incidence of infusion reactions, elevation in transaminases, and infections were similar between the 2 groups. These data support a role for TCZ in pulmonary AMR and establish preliminary evidence to design a randomized controlled trial of IL-6 inhibition for the management of AMR. [ABSTRACT FROM AUTHOR]

Acute interstitial pneumonia (AIP), also known as Hamman–Rich syndrome, is a rare and rapidly progressive idiopathic interstitial lung disease with a high mortality rate. Treatment is limited to supportive care and empirical high-dose steroids; however, outcomes are generally poor. There are few reports of lung transplantation (LTx) in patients with AIP. We retrospectively identified patients with AIP among those who underwent LTx at our center between January 2008 and December 2020. During the study period, 4 patients with AIP underwent bilateral LTx: 3 men and 1 woman, between 30 and 57 years of age. The lung allocation score ranged between 71 and 89. Of the 4 patients, 2 needed extracorporeal membrane oxygenation and mechanical ventilation (MV) and 1 needed MV preoperatively. Time of onset to transplant ranged from 1 to 3 months. None of the patients had primary graft dysfunction after LTx; 2 had acute cellular rejection and 1 had chronic lung allograft dysfunction. The 4 patients are alive with survival ranging between 1 and 12 years after LTx. AIP should be considered in patients with acute respiratory failure without a clear etiology. Our study showed that LTx led to good outcomes and should be considered as a treatment option in appropriate candidates. [ABSTRACT FROM AUTHOR]

Innate immune pathways early after pulmonary transplantation have been shown to cause primary graft dysfunction (PGD) and also predispose to late graft failure. Recent studies in animal models have elucidated critical mechanisms governing such innate immune responses. Here, we discuss pathways of inflammatory cell death, triggers for sterile and infectious inflammation, and signaling cascades that mediate lung injury early after transplantation. These studies highlight potential avenues for lung-specific therapies early following lung transplantation to dampen innate immune responses and improve outcomes. [ABSTRACT FROM AUTHOR]

We previously developed molecular assessment systems for lung transplant transbronchial biopsies (TBBs) with high surfactant and bronchial mucosal biopsies, identifying T-cell‒mediated rejection (TCMR) on the basis of the expression of rejection-associated transcripts, but the relationship of rejection to graft loss is unknown. This study aimed to develop molecular assessments for TBBs and mucosal biopsies and to establish the impact of molecular TCMR on graft survival. We used microarrays and machine learning to assign TCMR scores to an expanded cohort of 457 TBBs (367 high surfactant plus 90 low surfactant) and 314 mucosal biopsies. We tested the score agreement between TBB–TBB, mucosal–mucosal, and TBB–mucosal biopsy pairs in the same patient. We also assessed the association of molecular TCMR scores with graft loss (death or retransplantation) and compared it with the prognostic associations for histology and donor-specific antibodies. The molecular TCMR scores assigned in all the TBBs performed similarly to those in high-surfactant TBBs, indicating that variation in alveolation in TBBs does not prevent the detection of TCMR. Mucosal biopsy pieces showed less piece-to-piece variation than TBBs. TCMR scores in TBBs agreed with those in mucosal biopsies. In both TBBs and mucosal biopsies, molecular TCMR was associated with graft loss, whereas histologic rejection and donor-specific antibodies were not. Molecular TCMR can be detected in TBBs regardless of surfactant and in mucosal biopsies, which show less variability in the sampled tissue than TBBs. On the basis of these findings, molecular TCMR appears to be an important predictor of the risk of future graft failure. ClinicalTrials.gov NCT02812290. [ABSTRACT FROM AUTHOR]

A 68-year-old man with interstitial pulmonary fibrosis underwent bilateral lung transplantation. Histopathologic examination of hilar lymph nodes in the explanted lungs showed effacement of normal nodal architecture by the proliferation of small lymphocytes, consistent with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL). Unexpectedly discovered malignancies at the time of lung transplantation is uncommon, especially in the lymph nodes. The clinical management was challenging because of attempts to balance treatment of CLL and immunosuppressive treatment to prevent graft rejection. Here, we report a case of incidentally detected CLL in hilar lymph nodes with explanted lungs and review the relevant literature. [ABSTRACT FROM AUTHOR]

Background Bronchiolitis obliterans syndrome (BOS), chronic lung allograft rejection, remains an impediment for the function of the transplanted organ. In this study, we defined the role of the microRNA (miRNA) miR-144 in fibroproliferation leading to BOS. Methods Biopsy specimens were obtained from 20 lung transplant recipients with BOS( + ) and 19 without BOS( – ). Expression of miR-144 and its target, transforming growth factor-β (TGF-β)–induced factor homeobox 1(TGIF1), were analyzed by real-time polymerase chain reaction and Western blot. Overexpression of miR-144 and luciferase reporter genes were performed to elucidate miRNA-target interactions. The function of miR-144 was evaluated by transfecting fibroblasts and determining the response to TGF-β by analyzing Sma- and Mad-related family (Smads), fibroblast growth factor, TGF-β, and vascular endothelial growth factor. Smooth muscle actin-α–positive stress fibers and F-actin filaments in lung fibroblasts were analyzed by immunofluorescence. Results Analysis of miR-144 in the biopsy specimens demonstrated 4.1 ± 0.8-fold increases in BOS + compared with BOS – patients, with a significant reduction in TGIF1 (3.6 ± 1.2-fold), a corepressor of Smads. In vitro transfection confirmed that over-expression of miR-144 results in a reduction in TGIF1 and an increase in SMAD2, SMAD4, fibroblast growth factor-6, TGF-β, and vascular endothelial growth factor. Increasing miR-144 by transfecting, increased smooth muscle actin-α and fibronectin, and knockdown of miR-144 diminished fibrogenesis in MRC-5 fibroblasts. Conclusions miR-144 is a critical regulator of the TGF-β signaling cascade and is over-expressed in lungs with BOS. Therefore, miR-144 is a potential target toward preventing fibrosis leading to BOS after lung transplant. [ABSTRACT FROM AUTHOR]

Aim: De novo autoantibodies (autoAbs) against lung restricted autoantigens, namely k-alpha 1 tubulin (KAT) and collagen type V (colV), develop following transplant but their role in allograft rejection remains unclear. Using the murine model of lung transplant we investigated whether these autoAbs can abrogate immunosuppression mediated tolerance of lung allografts and induce rejection of syngeneic grafts. Methods: Abs to KAT, ColV and isotype control (n =5/group) were administered in Bl/6 murine recipients of MHC-mismatched Balb/c single left lung allografts that were tolerized using costimulatory blockade (MR1 and CTLA4-Ig). ELISPOT was used to analyze antigen specific T cells. Graft rejection was characterized using histochemistry. Syngeneic single left lung transplants were performed in B/6 mice following which Abs to KAT, ColV and isotype control were injected. Results: Lung allografts showed no rejection following co-stimulatory blockade. Administration of either KAT or colV autoAbs, but not isotype control, led to allograft rejection (but not native lungs) by day 45. This correlated with infiltration of IFN and IL-17 secreting Tcells specific to the lung-restricted autoantigens (but not Collagen II) as well as donor MHC antigens (but not against third party MHC antigens). Either KAT or colV autoAbs alone induced immunity against the other lung restricted autoantigen as well but not against non-lung antigen Collagen II. Administration of either colV or KAT autoAbs led to the rejection of syngeneic left lung grafts (but not native lungs) that was associated with infiltration of autoantigen specific IFN and IL-17 secreting T cells. Conclusions: De novo autoAbs can abrogate immunosuppression mediated lung allograft tolerance. Autoabs can lead to graft rejection in the absence of alloimmunity as evident by rejection of syngeneic grafts. AutoAbs also lead to epitope spreading and development of additional autoimmune responses against target tissue-restricted as well as donor MHC antigens. [ABSTRACT FROM AUTHOR]