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Purpose Chronic lung allograft dysfunction (CLAD) is the main culprit for low survival after human lung transplantation (LTx). Within the clinical identification of CLAD, the immunological enigma of chronic rejection was lost. This is difficult to study in the complex patient setting; but an appropriate experimental model may help. Our goal was to further elaborate our mouse model of chronic rejection by implementing in vivo microCT (µCT). Methods Using the orthotopic single left LTx model with cuffing method, isografts (n=9; C57BL/6N to C57BL/6N) and allografts (n=8; Balb/c to C57BL/6N) were transplanted. Mice received daily immunosuppression with 10 mg/kg cyclosporine A and 1.6 mg/kg methylprednisolone for 10 weeks. In vivo respiratory-gated time resolved µCT (SkyScan 1278, Bruker) was performed at postoperative week 1, 5 and 10, lung density and volume (at in and expiration) were quantified. Results In 1 isografts technical failure was observed (on both CT and histology), the other 8 demonstrated normal lung structure at week 10. 5 isografts had normal lung density at week 1, 5 and 10 (1.03±0.02; 1.04±0.01; 1.01±0.02), compared to 3 isografts which had significant increased lung density at week 1 (1.22±0.01; p Conclusion Longitudinal µCT is useful to investigate lung volume, lung density, lung ventilation/tidal volume of the transplanted lung and can identify and monitor the evolution/severity of both chronic rejection and primary graft dysfunction (PGD).

Purpose Connective tissue growth factor (CTGF) is an important mediator in several fibrotic diseases, including lung fibrosis. We investigated CTGF expression in chronic lung allograft dysfunction (CLAD) and pulmonary graft-versus-host disease (GVHD) by analyzing CTGF expression in broncho-alveolar lavage (BAL) fluid, plasma and lung tissue. Methods Sixty matched lung transplant patients were included (stable, n=20; bronchiolitis obliterans syndrome (BOS), n=20, restrictive allograft syndrome (RAS), n=20). CTGF expression was analyzed in BAL 3m post-transplant, 1y post-transplant, and at CLAD diagnosis or 2y post-transplant for stable patients. Explant lung tissue of CLAD (BOS, n=20; RAS, n=20), pulmonary GHVD (n=9), and discarded donor lungs (n=20) was immunohistochemically stained for CTGF. Results BAL CTGF protein expression was significantly higher at 3m post-transplant in patients who later developed RAS compared to stable or BOS patients (ANOVA p=0.028); while CTGF expression was similar at 1y post-transplant (ANOVA p=0.20). At CLAD diagnosis, CTGF expression was significantly increased in RAS compared to stable (p=0.0007) and BOS (p=0.042). Serial analysis revealed no difference in CTGF values between time points for stable and BOS patients (ANOVA p=0.84, p=0.92), whereas CTGF levels were significantly higher in RAS at CLAD diagnosis compared to 1y post-transplant (ANOVA p=0.029). CTGF plasma values were similar between BOS, RAS, and stable (ANOVA p=0.74). Immunohistochemistry revealed a higher percentage and intensity of CTGF positive respiratory epithelial cells in BOS and RAS lungs compared to controls (ANOVA p Conclusion Higher CTGF expression is present in BAL from RAS patients at CLAD diagnosis. Lung tissue CTGF expression is increased in end-stage RAS, BOS and pulmonary GVHD. Our results suggest a potential role for CTGF in CLAD, especially RAS, and pulmonary GVHD, which warrants further investigation of CTGF and its potential therapeutic modulation in these conditions.

Introduction Donor-transmitted vascular tumors are a rare complication after lung transplantation. Case Report A 35-year-old woman underwent bilateral lung transplantation for primary ciliary dyskinesia. Three years post-transplant, a nodule in the right upper lung lobe was detected on routine computer tomography. Wedge resection showed a hemangioma. One year later, two new lung nodules, as well as two liver lesions appeared, and vascular lesions without signs of malignancy were diagnosed on laparoscopic liver biopsies. After switching from tacrolimus to sirolimus, the volume of the lesions significantly decreased. However, two years later, mixed solid tissue lesions developed in both ovaries, while the lung and liver lesions gradually increased in volume again. Histological examination after bilateral salpingectomy was compatible with bilateral angiosarcoma. Tumor analysis by haplotyping and human leukocyte antigen typing showed mixed donor-chimerism, proving that the tumoral lesions in the lungs and ovaries were of donor origin. In retrospect, the donor became brain death following brain surgery complications for a previously biopsy-proven cerebral hemangioma, which is believed to have been a precursor lesion of this vascular malignancy. Summary Our case highlights a unique course of donor-related angiosarcoma, finally diagnosed 6 years after lung transplantation. Donor-origin of tumors detected in solid organ recipients should always be suspected in case of uncommon disease course or histology, and proper tissue-based diagnosis using sensitive techniques should be pursued, given the possible implications for treatment and outcome of other organ recipients in case of multi-organ donation.

Purpose “Chronic rejection” (CR) after lung transplantation (LTx) is considered to be a cellular and humoral immune response, accompanied by angiogenesis and fibrosis, clinically denominated as chronic lung allograft dysfunction (CLAD). We aimed to reinvestigate the chronological stages and spatial organization of the immune response of CR. Methods Orthotopic single LTx was performed to create isograft (n=9; C57BL/6N to C57BL/6N) and two allograft (n=16; BALB/c to C57BL/6N) subgroups: 1/ observational group (n=8), with serial sacrifice at week 1, 3, 5 and 8 to evaluate the sequential, spatial and cellular events of CR; and 2/ validation group (week 10; n=8) to assess variation within CR. All mice received daily immunosuppression of 10 mg/kg cyclosporine A and 1.6 mg/kg methylprednisolone. Results In 1 isograft technical failure occurred and 8 had normal lung architecture at week 10. In 3 allografts failure occurred: 2 in the observational, 1 in the validation group. Histological evaluation of allografts allowed reconstruction of CR: STAGE 1: innate inflammation around end-arteries; STAGE 2: innate immune cells around end-arteries and end-venules; STAGE 3: adaptive immune cell organization around end-arteries; innate immune cells around end-venules; pleural infiltration of lymphocytes; STAGE 4: fibrosis around end-arteries with end-arteritis obliterans; adaptive immune cells around the end-venules; pleural lymphatic vessel growth and fibrosis; bronchiolar wall folding and sporadic intraluminal fibrotic plugging. In the validation group, we identified 2 mice in STAGE 2, 2 in STAGE 3 and 3 in STAGE 4. µCT confirmed the progression of severe (stage 4) vs mild (stage 2-3) in lung attenuation (1.05±0.04 vs 1.14±0.01; p=0.002) (Figure) and total and tidal volume. Conclusion CR demonstrated an innate onset, evolving to adaptive organization and fibrosis, starting at end-arteries and then spreading towards venules, pleura and airways. This pattern seems to resemble RAS after human LTx.

Purpose Donation after circulatory death (DCD) is propagated to expand the lung transplant (LTx) organ donor pool. Using the International ECLS Registry database, we compared DCD vs DBD LTx survival in the context of intraoperative extracorporeal life support (ECLS). We hypothesize comparable survival outcomes and ECLS usage between donor groups. Methods Patients undergoing double-lung transplant were included from multiple institutions in US & Europe. Patients were stratified by donor type (DCD, DBD). Differences between groups in ECLS usage (yes/no) were analyzed with Chi-square testing or Fisher's exact test. Donor, recipient, and procedural characteristics, including the primary outcome of post-operative survival, were analyzed using Wilcoxon rank sum test or Chi-square testing. Propensity matching was used with Kaplan-Meier survival curves and log-rank testing to assess mortality between groups with and without ECLS. Endpoints Analysis of differences in patient/donor demographics, pre-operative, intra-operative and post-operative ECLS usage, post-operative complications, and patient survival will be used to compare the DCD and DBD donor groups. A total of 866 double lung transplantations (DLT), 72 DCD and 794 DBD cases, were preliminarily analyzed. DCD had older mean donor age (p=0.003), and higher post-operative pneumonia rates in DCD (p=0.01). Groups were different in the type of intra-operative ECLS support required (CPB, ECMO, Modified bypass) (p=0.014), total ischemic time (p=0.0001), and post-op ECMO (p=0.06). Mortality analysis showed no increased risk for DCD vs DBD groups before discharge (HR 1.31; CI- 0.43, 3.96; p=0.63), at 90-days (HR 1.49; CI- 0.35, 6.31; p=0.58), and 1-year (HR 0.93, CI-0.33, 2.60; p=0.89). Figure shows KM curves before and after propensity matching with/without ECLS. Further analysis will be done as the ECLS Registry patient volume increases.

Purpose During lung transplantation, donor biopsies are collected for histologic and biomarker assessments to understand lung injury. Samples are often taken from a single location and it is unknown whether this is truly representative of the injury across the organ. The objective of this study was to investigate the uniformity of cytokine mRNA expression in tissue samples collected from different locations in donor lungs. Methods Eight unused donor lungs were inflated, flash-frozen in liquid nitrogen, and partitioned into 10 to 15 slices from apex to base. Five 1 cm3 biopsies were taken from each lung; three were consistently taken from the third, sixth, and ninth slices, while two were taken from the lingula and a noted potential injury site. Three pieces of each biopsy were used to measure mRNA expression of IL-6, IL-8, IL-10, and IL-1β as markers of lung inflammation by PCR in a total of n=120 samples from the eight lungs. Intra-biopsy and intra-lung variations were analyzed with equal-variance tests, coefficients of variance, one-way ANOVA, and pairwise mean comparisons. Results Across all donors, the intra-biopsy equal-variance F-values ranged from 0.19-0.95 with means of 0.33, 0.57, 0.62, and 0.58 for IL-1β, IL-6, IL-8, and IL-10. The mean biopsy coefficient of variance was 25.9% across all donors. The mean comparisons of biopsies in each donor showed that the three consistent slices were identical in donors rejected for logistics and thrombotic emboli. Both the lingula and focal injury biopsies demonstrated larger differences in cytokine expression from the rest of the donor lung. Conclusion While intra-biopsy variances were present, they were small and consistent across multiple biopsies in donors, indicating the reliability of repeated analysis of banked specimens. Lungs rejected for non-graft related reasons demonstrated more consistent gene expression. The lingula is not a representative site as it often differed from other biopsies in all donors. We conclude that a donor lung biopsy taken from an area other than the lingula reflects the overall condition of the lung, unless there is obvious localized injury (e.g. infection) which has a unique profile. These findings will reassure the scientific community that a biopsy of the donor lung is indeed representative of the whole lung, and will help to guide diagnostic and therapeutic interventions in donor lungs for transplantation.

Purpose Cold ischemic time (CIT) may adversely affect clinical outcomes after lung transplantation (LTx). Most centers restrict CIT to less than 6-8 hours. However, to improve donor utilization, centers are increasingly pushing the envelope of CIT. To clarify the effect of CIT on graft function and clinical outcomes, we analyzed the international multicenter ECLS in LTx registry. Methods the ECLS registry collects LTx data from 6 US and 2 European centers between January 2016 and March 2020. Single LTx, ex vivo lung perfusion, and multiple organ transplants were excluded. CIT was analyzed as a continuous variable and divided in balanced tertiles. The reperfusion of the second lung was considered the end of the CIT. Models were adjusted by 11 clinical factors. Our endpoints were PGD at T0, T24, T48 and T72 hours according to the 2016 ISHLT consensus. Length of stay, death within 90 days and at one year of follow-up was investigated. A univariate and multivariate analysis was performed. Pearson correlation analysis was used to assess effect of CIT on length of stay (LOS). Results The inclusion criteria were met by 798 patients. The mean and median CIT was 418 and 397 min, respectively. Adjusted analysis suggests that total CIT was not associated with PGD grade 3 at 48 and 72 hours (OR1.24, 0.87-1.75). However, CIT was associated with several other markers of graft dysfunction and resource utilization including PGD3 T0 (OR1.5, 1.06-2.13), tracheostomy (OR1.93, 1.3-2.87), post-op ECMO (OR3.47, 2.21-5.45), renal failure requiring dialysis (OR1.8, 1.13-2.86), death within 90 days (2.41, 1.42-4.09), death in hospital (OR2.53, 1.47-4.35), and death within one year (OR 2.37, 1.43-3.94). Total ischemic time was also independently associated with LOS (P Conclusion In a multicenter international registry, increasing CIT was associated with increased PGD at T0, higher postoperative morbidity and worse first year survival. Although patients can be transplanted with extended cold ischemic times when absolutely needed, this practice is associated with greater resource utilization and likely impact on survival.

Purpose The neutrophil is the most abundant blood leukocyte in humans and the first cell involved in an immune response like infection, rejection or injury of the lung. Neutrophils were long considered as simple short-lived cells. However, several distinct neutrophil subsets, maturation and activation stages with functional heterogeneity are identified. This spiked our interest to perform an in-depth neutrophil characterization, focusing on their maturation and activation characteristics, in broncho-alveolar lavage fluid (BALF) and peripheral blood of lung transplantation (LTx) patients who received standard immunosuppression. Methods BALF and blood neutrophils were microscopically evaluated and identified by multicolor flow cytometry (CD16+/CD66b+) to examine expression of maturation/activation markers and adhesion molecules (CD10, CD62L, CD11b, CD11c, CD15, HLA-DR) and chemoattractant receptors (CXCR1-4, CCR1-3, FPR1-2, C5aR and BLTR1) within healthy control subjects (n = 11), stable LTx patients (n = 8-14), and LTx patients with infection (n = 9) or chronic lung allograft dysfunction (n = 2-6). Results LTx patients had a significantly higher (p Conclusion We demonstrated a compromised maturation of neutrophils in peripheral blood and BALF of LTx patients versus healthy controls. In addition, we observed a more activated status of BALF neutrophils with a surprisingly increased expression of CXCR3 on their membrane in stable LTx patients.

Purpose Ex vivo lung perfusion (EVLP) improves organ quality and makes the lungs safe that were previously unsuitable for bilateral lung transplant (BLT). We investigated EVLP utilization in BLT from our ECLS registry and compared the outcome in DCD and DBD. Methods Patient data involving BLT were collected from the National ECLS Registry and stratified by EVLP in DCD and DBD. ECLS usage information was obtained and analyzed with Chi-square testing or Fisher's exact test to determine a relationship with donor groupings in EVLP. Lung transplant procedure details, patient and donor demographics and post-operative survival were analyzed using Wilcoxon rank sum test or Chi-square testing to determine distribution. Kaplan-Meier survival curves with log-rank testing to assess mortality between donor groups with EVLP use. P-values Results Out of 932 BLT, there were total 66 EVLP: 20 DCD and 46 DBD cases. Demographics data showed age:54±14 years, BMI 25 ± 5 kg/m2, 34M, LAS - 44±14, PHTN - 51 patients, prior ECMO - 2, donor age 38 ± 14, donor gender - 38M, total ischemic time - 578±149 min, Use of ECLS - CPB:7, ECMO:26, Modified bypass:8, Off-pump:25, PGD at 48h-72h - 18, Post-op ECMO: VA - 3, VV - 12, VVA - 1. Death before discharge - 9, before 90d - 5, before 1yr - 9. Tracheostomy - 15 patients, post-op pneumonia - 10 patients, median length of stay - 22 days. Unadjusted comparison reveals significant differences in 1yr survival with EVLP vs DBD vs DCD utilization (HR:2.16; CI- 1.00-4.66; p=0.05), but when adjusted, there were no significant differences (HR:0.93; CI- 0.33-2.60; p=0.883). Kaplan-Meier curve showed no statistical significance in DCD and DBD groups when used for EVLP. Conclusion EVLP utilization did not have any significant effect in survival when used in DCD and DBD transplantation. It suggests EVLP can be safely utilized in both groups thereby increasing the donor pool.

Purpose Post-infectious bronchiolitis obliterans (PIBO) forms a chronic obstructive lung disease in children following a severe viral respiratory infection. Subsequent dysanaptic lung growth, with differential development of the alveolar compartment over the airway compartment, was clinically described, but remains elusive. We therefore performed a detailed 3D airway characterization in PIBO compared to bronchiolitis obliterans syndrome (BOS) after lung transplantation and discarded donor lungs. Methods Explant lungs from matched adult patients who underwent lung transplantation for end-stage PIBO (n=5), redo lung transplantation patients with end-stage BOS (n=5), and discarded donor lungs (n=5) were included. Lungs were air-inflated and frozen in fumes of liquid nitrogen. Ex vivo computed tomography (CT) scans (resolution 700 µm) were obtained and used for radiologic scoring and semi-automated 3D airway segmentation. Next, frozen lungs were sampled on matched locations (n=4/lung) and scanned with microCT (resolution 10 µm). Results Radiologic scoring indicated more airway wall thickening (p=0.079), bronchial dilatation (p=0.087), and pleural thickening (p=0.071) in PIBO vs BOS. The number of airways per generation was similar between groups (p=0.53), but airway diameters were increased in PIBO (generation 6-11) and in BOS lungs (generation 7-10) compared to controls, without differences between PIBO and BOS. Significantly more airways ended in BO lesions in BOS vs PIBO (p=0.016, mean 25.60% vs 12.60%), although the size of the BO lesions was increased in PIBO vs BOS (p=0.032, median 27.23mm³ vs 5.01mm³). Subsequent micro CT assessment revealed a significant lower number of terminal bronchioles (TB) in PIBO (p=0.0009, PIBO: mean 3131 TB/lung, BOS: 8360 TB/lung, controls: 10342 TB/lung), although diameters of TB were similar across groups (p=0.37). In addition, alveolar spaces tended to be larger in PIBO (p=0.070). 3D micro CT analysis confirmed that in BOS, BO lesions are only segmental with preserved TBs, while in PIBO, the airway is completely lost following the obstruction. Conclusion PIBO lungs displayed a more than two-fold decrease in TB compared to BOS, with fewer but larger BO lesions and non-reopening of airways distal from BO. Our findings provide potential pathophysiologic evidence of dysanaptic lung growth in PIBO.

© 2017 by Thieme Medical Publishers, Inc. Sarcoidosis is a chronic systemic inflammatory disease which is histopathologically characterized by the presence of noncaseating granulomas. When the extent of the disease is limited, without endangering the function of affected organs, clinical observation can be sufficient given that in a majority of cases, inflammation will subside with time. In more advanced sarcoidosis, especially when one or more specific organs are threatened, immunomodulatory treatment, of which steroids are the key element, over a prolonged period of time, in general, may attenuate disease activity. Treatment-refractory sarcoidosis (due to the lack of efficacy, drug toxicity or intolerability) may be progressive and, although infrequent, can result in end-stage organ failure. In these selected cases, solid organ transplantation (SOT) should be considered. In this article, SOT is positioned within the organ-specific treatment of systemic sarcoidosis and data on outcome after transplantation are discussed. ispartof: Seminars in Respiratory and Critical Care Medicine vol:38 issue:4 pages:538-545 ispartof: location:United States status: published

Purpose In 2005, an ISHLT working group proposed a grading system for primary graft dysfunction (PGD) following lung transplantation (LTx), based on oxygenation (P/F) and chest X-ray. This system was revised in 2016. The aim of this study is to compare the impact of the 2016 revised versus the original 2005 grading system on PGD prevalence and early post-LTx outcome. Methods All patients receiving double LTx at our institution between 12/2016 and 01/2018 (n=75) were retrospectively studied. P/F ratios were calculated and X-rays were scored by two experts blinded for clinical information at time (T) points 0, 24, 48, and 72 hours. PGD grading was determined separately according to 2005 and 2016 PGD definition. When multiple P/F ratios were available, the lowest P/F was used. Results Results are visualized in figure 1. PGD distribution at T0, T24, T72 differed between 2005 and 2016 (p Conclusion PGD grading differs between the original and the new PGD scoring system with a higher proportion of lower grades according to the 2016 definition at early time points. This might be explained by the more prominent role of chest radiography in the 2016 classification for PGD 0 regardless of the P/F ratio. On the other hand, according to the 2016 classification system, extubated patients are no longer automatically scored as PGD-0 or PGD-1, which might explain the higher proportion of PGD3 at T72. Early outcome was comparable between the two systems when patients suffered from PGD3 at any time point after transplantation. The impact of PGD grading on long-term outcome should be further investigated.

Purpose Prior single center experiences suggest that use of ECLS during lung transplantation (LT) increases the risk of PGD. Here we analyze the effects of intraoperative ECLS time on PGD after LT in a multicenter ECLS registry. Methods The ECLS in LT registry includes data on bilateral LTs from 8 centers (2 from Europe, 6 from United States). The registry excludes single lung transplants and multi-organ transplants and defines primary graft dysfunction according to the ISHLT 2016 consensus statement. Herein, we refer to PGD as a single case developing PGD3 at time 48 and/or 72 hours. We explored the risk of intraoperative ECLS time on the incidence of PGD and death within 90 days using adjusted and unadjusted logistic regression and receiver operating curve (ROC) analysis. Results We identified 297 ECLS patients with intraoperative support times available between January 2016 and August of 2019. Breakdown of cases were as follows: 44% CPB, 66% ECMO (16% VV, 64%VA/VVA, 20% modified bypass-VA). Out of these, 35.6% developed PGD and 6% died within 90 days. Median time of ECLS support was 206 minutes (62-686 minutes). The median time of support was 200 minutes in patients without PGD and 206 minutes in cases with PGD. The median time of support was 202 minutes in patients who survived 90 days compared to 271 minutes in patients who did not survive 90 days. Our unadjusted and adjusted logistic regression analysis showed that time of ECLS was not associated with PGD irrespective of the mode of ECLS (CPB v ECMO). In addition, ROC analysis showed an area under the curve for ECLS time of 0.51 suggesting poor predictability for PGD. Our unadjusted analysis showed that increased time on ECLS was significantly associated with death within 90 days (P=0.014) although this was of borderline significance after adjusting for risk factors (P=0.067). Furthermore, this effect was of borderline significance for CPB (P=0.07) and not significant for ECMO (P=0.17). Conclusion In an international multicenter registry on use of ECLS in LT, the time on ECLS did not alter the risk of PGD with either CPB or ECMO, although it was associated with perioperative death. Surgeons should limit the time spent on ECLS when feasible and consider ECMO for longer procedures.

Purpose Donor organ shortage, in combination with a 70% decline rate of offered donor lungs, results in significant wait list mortality and time with poor quality of life. Assessing donor lungs for transplant suitability is based on donors’ history, gas exchange, chest X-ray, bronchoscopy, and in situ visual inspection; but donor lung acceptance remains subjective. We performed an in depth histopathologic and radiologic assessment of retrieved but unused donor lungs. Methods We assessed 62 donor lungs not used for transplantation for various reasons between 2010 and 2019. These lungs were air-inflated, frozen, scanned with computed tomography, systematically sampled on 4 different locations, assessed macroscopically and microscopically by two experienced lung pathologists and by an experienced thoracic radiologist, all blinded for the reason of decline. Results Reasons for non-use are summarized in the figure. Thirty-nine (63%) lungs were not used for allograft-related reasons. In 13/39 (33%) lungs, the reason for decline could not be confirmed by histologic assessment (emboli, n=7; pneumonia, n=3; contusion, n=2; emphysema, n=1), in an additional 8/39 (21%) lungs, histologic abnormalities were only considered focal and mild (emphysema, n=5; pneumonia, n=3). In 16/39 (41%) lungs, radiology could not confirm the reason for decline. Twenty-three (37%) of 62 unused donor lungs were not transplanted due to extra pulmonary causes, of which 3 (13%) lungs displayed severe histologic abnormalities (pneumonia, n=2; emphysema, n=1), in addition to mild emphysema in 9 (39%) lungs and mild bronchopneumonia in 1 lung (4%). Radiology revealed ground-glass opacities in 8/23 (35%) and emphysema in 4/23 (17%) of these donor lungs. Conclusion Histologic and radiologic assessment of unused donor lungs revealed substantial discrepancy with the clinical reason for decline. Prior chest CT imaging and frozen sections in selected cases might contribute to adequate donor assessment and augment current yield of donor lungs.

Purpose To compare 5-year survival of lung transplant (LTx) recipients in donation after circulatory death (DCD) versus donation after brain-death (DBD) donors. Methods We examined the ISHLT Thoracic Transplant Registry data for LTx patients transplanted between 2003 and 06/2017 at 23 centers in North America, Europe and Australia participating in the DCD Registry. Distribution of continuous variables was summarized as median and interquartile (IQR) values. Mann-Whitney test was used to compare distribution of continuous variables and chi-square or Fisher's exact test for categorical variables. Kaplan-Meier survival rates after LTx during 2003-06/2016 were compared between DCD-III [Maastricht category III withdrawal of life sustaining therapy (WLST)] only and DBD using the log-rank test. Risk factors for 5-year mortality were investigated using Cox multivariate proportional-hazards model. Results The study cohort included 11,516 lung transplants, of which 1,090 (9.5%) were DCD transplants. DCD-III category comprised 94.1% of the DCD cohort. Among the participating centers, the proportion of DCD-LTx increased from 0.6% in 2003 to 15.2% in 2017. DCD donor management included extubation in 91%, intravenous heparin in 51% and pre-transplant normothermic ex-situ pulmonary allograft perfusion in 15%. Median time interval from WLST to cardiac arrest was 15 min [IQR: 11-22 min] and to cold flush 32 min [IQR: 26-41 min]. Compared to DBD, donor age was higher (47 [IQR: 34-55] vs 40 [IQR: 24-52] years), bilateral LTx was performed more often (88.3% vs 76.6%), more recipients had COPD/emphysema as transplant indication, and recipient hospital stay was longer (25 [IQR: 17-39] versus 18 [IQR: 12-29] days) in DCD-III (all p Conclusion This ISHLT DCD Registry report with 5-year follow-up demonstrated similar excellent long-term survival in DCD-III and DBD lung donor recipients in 23 experienced centers. These data support measures to implement and increase DCD LTx more widely.

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor with variable biological and clinical behavior. There is increasing experience with liver transplantation (LiTx) for hepatic EHE, even in cases of extrahepatic disease localization. Until now, no cases of lung transplantation (LuTx) had been reported for pulmonary EHE. This report describes three cases of EHE with multifocal disease in patients who underwent either serial or combined LiTx and LuTx.

Purpose Prior studies have explored the effects of cold ischemic time on survival but its effect on PGD is unclear. The current study analyzed an international multicenter ECLS in lung transplantation registry to clarify the effects of cold ischemic time on PGD. Methods The ECLS in lung transplantation registry includes data on bilateral lung transplants from 8 high volume (>40 transplants/yr) transplant centers (2 from Europe, 6 from United States). This registry excludes single lung transplants and multi-organ transplants and the current analysis excluded Ex Vivo Lung Perfusion (EVLP) cases. We defined primary graft dysfunction according to the 2016 ISHLT consensus document and considered PGD3 at time 48 or 72 hours as high-grade primary graft dysfunction (PGD). We defined cold ischemic time as the interval between donor cross clamp (cardiac arrest for donation after circulatory death cases) and the longest reperfusion time in the recipient. We explored the effect of the cold ischemic time on PGD and death within 90 days using univariate and multivariate logistic regression analysis. Results We identified 511 entries with complete ischemic times between January 2016 and August of 2019. The overall incidence of PGD was 30.7%. The mean cold ischemic time in the group that developed PGD was 406 minutes and 428 minutes in the group that did not develop PGD. Univariate regression analysis showed no effect of ischemic time on the incidence of PGD (P=0.12). ROC analysis yielded an area under the curve for cold ischemic time and PGD of 0.55 further suggesting that cold ischemic time was poorly predictive of PGD. Our adjusted analysis showed no effect of total ischemic time on PGD (P=0.75). Finally, both univariate and multivariate analysis failed to show significance for the effect of total ischemic time on death within 90 days (P=0.33 and P=0.54, respectively). Conclusion In a large multicenter registry, we could not identify an effect of duration of cold ischemic time on incidence of PGD or 90-day mortality. Practitioners should avoid using cold ischemic times in isolation to accept or decline a potential organ, although its effects on early reperfusion and long-term graft function require further study as does the extent of tolerable cold ischemia.

Purpose Pseudomonas aeruginosa (PA) is an established risk factor for chronic lung allograft dysfunction (CLAD) after lung transplantation (LTx). PA eradication in cystic fibrosis patients prevents pulmonary function decline. Therefore, we investigated the effect of PA eradication after LTx on CLAD-free survival, graft survival and pulmonary function. Methods Patients transplanted between 07/1991 and 02/2016 in our hospital with sufficient pulmonary function data, without redo LTx or CLAD onset before 09/2011 were retrospectively included and classified according to PA presence in respiratory samples between 09/2011 and 09/2016. PA positive patients were subsequently stratified according to success of PA eradication. CLAD-free and graft survival were compared between PA positive and PA negative patients and between patients with or without successful PA eradication. In addition, pulmonary function was assessed during the first year following PA isolation in both groups. Results CLAD-free and graft survival of PA negative patients (n=443, 82%) was better compared to PA positive patients (n=95, 18%) (p=0.0005, p=0.0011). PA eradicated patients (n=76, 80%) had better graft survival compared to patients with persistent PA (n=19, 20%) (p Conclusion PA eradication after LTx improves CLAD-free and graft survival and helps maintain pulmonary function.

Purpose Donor shortage remains a major obstacle associated with considerable mortality in patients waiting for lung transplantation (LTx). Objective donor lung assessment is crucial to obtain sufficient grafts of acceptable quality. We hypothesized that out of body chest CT may be an innovative way to assess grafts prior to LTx. Therefore, this study prospectively investigated the value of CT scan of donor lungs prior to LTx. Methods Between 12/2016 and 01/2018, all potential donor lungs were inspected in-situ, recovered and ex situ CT scanned during standard cold preservation. The transplant team and radiologist were blinded for the CT scan, which thus did not change the decision to transplant. CTs were scored for CT abnormalities and were compared between transplanted (Tx) and non-Tx grafts. In addition, CT of Tx grafts were compared between recipients developing PGD3 within 72 h (‘PGD3’) and recipients who did not (‘No PGD3’). Results In total, 75 lungs were transplanted and 25 were not transplanted, of which 19 were declined for poor graft quality and 6 for extrapulmonary malignancies or logistics. CT abnormalities (CSL, GGO, EMPHY) differed between Tx and non-Tx grafts (Figure 1A). In lungs declined for poor graft quality (n=19), the reason for decline was confirmed in 13 lungs, however 4 lungs had only limited CT abnormalities present. In 2 out of 7 lungs declined at retrieval for clinical suspicion of emphysema, no emphysema was present on CT. In addition, CT abnormalities (CSL, RET/IST) of Tx grafts also significantly differed between recipients with PGD 3 and without PGD 3 (Fig 1B). Conclusion Ex situ CT imaging of donor grafts during preservation is feasible and demonstrated significant differences between Tx and non-Tx grafts. Also grafts of patients with or without PGD3 differed in CT parameters. CT imaging could not confirm the reason for decline in 6 lungs, which might indicate an undisclosed graft potential and a role of CT imaging in donor assessment. The prognostic value of CT parameters on long-term outcomes remains elusive.

Purpose Humoral immunity is a fundamental element of chronic lung allograft dysfunction (CLAD) as shown by the presence of B cells and lymphoid follicles in the lung allograft. The formation of lymphoid follicles is under control of follicular helper T (TFH) cells, which also help B cells to differentiate into high-affinity alloantibody-producing plasma cells and memory B cells. The presence and role of circulating TFH cells in CLAD has not yet been investigated and is therefore the objective of our cross-sectional study. Methods Whole blood samples were collected from healthy controls (HC) (n=7) and lung transplant recipients (n=31: stable n=12, CLAD n=19). After peripheral blood mononuclear cell isolation, quantification of CD3+ T cells, CD4+ T helper (TH) cells and CXCR5+PD1+ TFH cells was performed using flow cytometry (LSR Fortessa, BD Bioscience). One-way ANOVA with multiple comparisons was used for statistical analysis. Results No differences were found in CD3+ T lymphocytes between groups, but percentages of CD4+ TH cells within the T cell population were decreased in CLAD versus HC (p=0.005) and the same trend was seen in stable patients versus HC (p=0.07). The number of TFH cells within the TH cells was lower in HC (p=0.044) and in CLAD patients (p Conclusion Circulating TFH cells are measurable in blood of lung transplant recipients by flow cytometry and are significantly decreased in patients with CLAD compared to stable lung transplant patients. TFH may play a role in immune activation after lung transplantation, however, further investigation is needed.

Purpose Orthotopic left lung transplantation (LTx) in mice is an accepted technique to model human post-LTx complications. However, in depth characterization and proper tools to assess chronic rejection (CR) in this model are lacking. Therefore, we developed a multimodal approach to monitor and characterize CR in murine LTx using a major genetic mismatch of donor and recipient under daily immunosuppression (Cyclosporine A (CsA) + Methylprednisolone (MP)). Methods 24 mice underwent LTx and were divided in 3 groups (n=8/group): isograft (BL6>BL6; 10mg CsA+1.0mg MP); allograft with a low dose of steroids (Balb/c>BL6, 10mg CsA+1.0mg MP) and allograft with a high dose of steroids (Balb/c>BL6; 10mg CsA+1.6mg MP). Follow-up included monitoring of immune activation by immunoglobulin (Igs) typing (IgM, IgA, IgE, IgG1, IgG2b, IgG2c and IgG3) and in vivo µCT imaging (lung volume and density) at week 1, 5 and 10 to assess structural changes. Additionally, end-point histopathology was evaluated. Results Lung volume changed significantly within 10 weeks (p=0.026) and was different between groups (p=0.0002). Lung density was significantly different between groups (p Conclusion Multimodal follow-up of transplanted animals using blood Igs and in vivo µCT imaging combined with histopathology are useful to monitor CR after LTx. Immunosuppression has a major influence on the outcome and has to be considered when modelling post LTx complications.

Purpose Ex vivo lung perfusion (EVLP) is considered a useful platform to evaluate, preserve and recondition grafts prior to lung transplantation (LTx). Reducing physical stress due to standard volume-controlled ventilation (VCV), might further prolong EVLP in time and reduce ventilator induced lung injury (VILI). An innovative approach might be the use of flow-controlled ventilation (FCV), a ventilation mode which controls inspiratory and expiratory flow. These properties can reduce atelectrauma and volutrauma related to standard VCV. This is the first study to evaluate the use of FCV during EVLP in a porince model. Methods Porcine lungs were mounted on EVLP after 2 hours of warm ischemia and divided into 2 groups (n=7/group). EVLP was maintained for 6 hours and physiological parameters were continuously recorded. In the first group, lungs on EVLP were ventilated standardly (VCV, 7 ml/kg). In the second group, lungs were ventilated using FCV (7ml/kg). After EVLP, W/D ratios were taken of the right lung and the left lung was frozen while inflated in liquid nitrogen vapors and CT scanned. Results Results are demonstrated in figure 1. Pulmonary vascular resistance (PVR) was comparable between VCV and FCV (p=0.52). FCV significantly increased oxygenation (P/F ratios) (p=0.01), and better maintained dynamic compliance (p=0.03). There was no difference in W/D ratios between the groups (p=0.16). CT density measurements were decreased by FCV (p=0.05). Conclusion FCV is feasible to ventilate pulmonary grafts during EVLP and improves oxygenation. The lower decline in compliance and lower CT density measurements in FCV might indicate a better preservation of alveolar recruitment since extravascular water content (W/D ratio) was similar between both groups. In conclusion, FCV ventilation might reduce injury related to standard volume-controlled ventilation. Using FCV mode during EVLP might stabilize and prolong EVLP time in the future and open the perspective to further actively recondition grafts.

Purpose Eosinophils are associated with the onset of chronic respiratory diseases like asthma and COPD. In lung transplantation, patients with increased bronchoalveolar lavage eosinophils demonstrated a worse chronic lung allograft dysfunction (CLAD)-free survival and overall survival. We investigated the association between blood eosinophilia, graft survival and CLAD-free survival after lung transplantation. Methods A retrospective analysis was performed including all transplanted patients within our center between 2011 and 2016 (n=376). Blood eosinophils were measured as part of the routine clinical follow-up including all measurements prior to 01/06/2019. A ROC analysis was performed to define cut-offs for blood eosinophilia and patients were subsequently divided in those with high blood eosinophilia vs. those with lower eosinophilia based on the defined cut-off. All patients received oral steroids as part of their standard immunosuppressive drug regimen. Results ROC analysis revealed that the optimal threshold for blood eosinophilia is >7.85% (p=0.0026) for overall survival and >7.75% (p=0.001) for CLAD-free survival. Using a threshold of >8%, 112 patients had high blood eosinophilia and 264 had low eosinophilia (16 patients developed high eosinophilia after CLAD). Patients with blood eosinophilia >8% demonstrated worse graft survival (p=0.004) and CLAD-free survival (p=0.0076) compared to those with lower blood eosinophilia. Within the high eosinophilia group, 65 (58%) patients were diagnosed with CLAD, of which 42 (37.5%) patients had BOS and 23 (20.5%) had RAS. In the group with lower eosinophilia, 80 (30.3%) patients developed CLAD with 71 (26.9%) BOS and 9 (3.4%) RAS (p Conclusion Lung transplant recipients with high blood eosinophilia (>8%) demonstrate inferior graft survival and CLAD-free survival, specifically RAS. These findings require further research and may lead to the development of an easy to use, non-invasive marker for poor transplant outcome.

Purpose Bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), have been identified as main phenotypes of chronic lung allograft dysfunction (CLAD), however patients can change phenotype. We aimed to describe incidence, prognosis, radiology, pulmonary function and pathology in this mixed group of CLAD. Methods We retrospectively assessed the chest CT-scans of all double lung patients transplanted between 2001 and 2015 with a FEV1 decline >20% of baseline. The diagnosis of RAS was made using a decline in TLC>10% compared to baseline or a decline in FVC>20% compared to baseline. A mixed group of CLAD was defined as patients developing a TLC or FVC decline with persistent CT opacities after initial CLAD diagnosis (without TLC or FVC drop) or vice versa. Results 44% of the patients developed CLAD (268/608) of which 77 developed persistent CT opacities (29%). 45 patients were immediately diagnosed with RAS. We found twenty-seven patients with a mixed phenotype of CLAD (25 BOS to RAS, 2 RAS to BOS). In 5 patients persistent pleuroparenchymal opacities were found without an additional decrease in FVC or TLC. The median time between CLAD and mixed diagnosis was 2Y (IQR 0.9-4.8Y). Median survival after CLAD diagnosis was longer in the mixed group compared to the RAS group (4.3Y vs 1.17, p=0.0052), however survival after the appearance of opacities was similar in both groups (p=0.39). We found significantly more emphysema patients in the mixed group (p=0.0062), with a lower FEV1 (p Conclusion We demonstrated that 35% of patients showed a mixed phenotype of CLAD, which showed difference in survival, demographics, pulmonary function, radiology and pathology compared to RAS patients.

Purpose Chronic pulmonary graft versus host disease (cpGvHD) is a diverse and underestimated complication following allogenic hematopoietic stem cell transplantation (alloHCT). We aimed to compare the airway architecture with chronic lung allograft dysfunction (CLAD) after lung transplantation (LTx). Methods Inflated explant lungs from cpGvHD patients, retrieved at lung transplantation, were compared to lungs with CLAD following LTx and unused donor lungs as controls, matched according to age and gender, using a combination of CT, whole lung microCT (80µm resolution), tissue microCT (10µm resolution) and histopathology (n=6 per group), aiming to quantify histopathologic findings in (small) airways. Results Following alloHCT, 3 patients presented as BOS and 3 patients showed interstitial changes and restriction. CT analysis demonstrated a strong similarity between BOS after LTx and post- alloHCT, evidenced by a similar airway count compared to controls but severe (>50%) airway obstruction from generation 7, with whole lung microCT demonstrating that 70.8% of the airways ended in obstruction (figure). Further analysis indicated that bronchioles either collapsed or accumulated matrix along a segment of the airway (figure). In patients with restriction and interstitial changes following alloHCT, the degree of airway obstruction was lower compared to BOS post-alloHCT, but similar to RAS post-LTx, showing a lower proportion of airway obstruction (±35%), decreased number of terminal bronchioles per lung (p Conclusion We observed similarities in airway pathology in chronic pulmonary GvHD and CLAD following LTx, suggesting similar pathophysiological mechanisms.

Isolated lung transplantation (LuTx) and liver transplantation are established treatments for irreversible lung and liver failure. Combined liver and lung transplantation (cLiLuTx) is a less common, but approved therapy of combined organ failure, mostly applied in patients suffering from progressive cystic fibrosis and advanced liver disease. We report a patient who was listed for LuTx due to end-stage chronic obstructive pulmonary disease and who developed drug-induced acute hepatic failure. The only therapeutic option was hyper-urgent cLiLuTx. To correct the poor coagulation in order to reduce the per-operative risk of bleeding, the liver was transplanted first. In anticipation of the longer lung preservation time, cold flushed lungs were preserved on a portable lung perfusion device for ex vivo normothermic perfusion for 11 h 15 min, transplanted sequentially off-pump, and reperfused after a total ex vivo time of 13 h 32 min and 16 h for the first and second lung, respectively. Ten months later, the patient is doing well and no rejection occurred. Normothermic ex vivo lung perfusion may help to prolong preservation time, facilitating long-distance transport and combined organ transplantation. ispartof: American Journal of Transplantation vol:14 issue:10 pages:2412-2416 ispartof: location:United States status: published

Despite donor organ shortage, a large proportion of possible donor lungs are declined for transplantation. Criteria for accepting/declining lungs remain controversial because of the lack of adequate tools to aid in decision-making. We collected, air-inflated, and froze a large series of declined/unused donor lungs and subjected these lung specimens to CT examination. Affected target regions were scanned by using micro-CT. Lungs from 28 donors were collected. Two lungs were unused, six were declined for non-allograft-related reasons (collectively denominated nonallograft declines, n = 8), and 20 were declined because of allograft-related reasons. CT scanning demonstrated normal lung parenchyma in only four of eight nonallograft declines, while relatively normal parenchyma was found in 12 of 20 allograft-related declines. CT and micro-CT examinations confirmed the reason for decline in most lungs and revealed unexpected (unknown from clinical files or physical inspection) CT abnormalities in other lungs. CT-based measurements showed a higher mass and density in the lungs with CT alterations compared with lungs without CT abnormalities. CT could aid in the decision-making to accept or decline donor lungs which could lead to an increase in the quantity and quality of lung allografts.