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Survival Determinants in Lung Transplant Patients With Chronic Allograft Dysfunction

Verleden, Geert M.1,4; Vos, Robin1; Verleden, Stijn E.2; De Wever, Walter3; De Vleeschauwer, Stéphanie I.2; Willems-Widyastuti, Anna2; Scheers, Hans2; Dupont, Lieven J.1; Van Raemdonck, Dirk E.1; Vanaudenaerde, Bart M.2

doi: 10.1097/TP.0b013e31822bf790
Clinical and Translational Research

Background. Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality after lung transplantation.

Methods. In this retrospective single-center study, we aimed to identify different phenotypes of and risk factors for mortality after CLAD diagnosis using univariate and multivariate Cox proportional hazard survival regression analysis.

Results. CLAD was diagnosed in 71 of 294 patients (24.2%) at 30.9±22.8 months after transplantation. Pulmonary function was obstructive in 51 (71.8%) of the CLAD patients, restrictive in 20 (28.2%) patients, of whom 17 had persistent parenchymal infiltrates on pulmonary computer tomography (CAT) scan. In univariate analysis, previous development of neutrophilic reversible allograft dysfunction (NRAD, P=0.012) and a restrictive pulmonary function (P=0.0024) were associated with a worse survival, whereas there was a strong trend for early development of CLAD and persistent parenchymal infiltrates on CAT scan (P=0.067 and 0.056, respectively). In multivariate analysis, early development of CLAD (P=0.0067), previous development of NRAD (P=0.0016), and a restrictive pulmonary function pattern (P=0.0005) or persistent parenchymal infiltrates on CAT scan (P=0.0043) remained significant.

Conclusion. Although most CLAD patients develop an obstructive pulmonary function, 28% develop a restrictive pulmonary function, compatible with the recently defined restrictive allograft syndrome phenotype. Early-onset CLAD, previous development of NRAD, and the development of restrictive allograft syndrome are associated with worse survival after CLAD has been diagnosed.

1 Lung Transplantation Unit, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.

2 Laboratory of Pneumology, Katholieke Universiteit Leuven, Leuven, Belgium.

3 Department of Radiology, Katholieke Universiteit Leuven, Leuven, Belgium.

This work was supported by the Research Foundation Flanders (FWO) grants G.0643.08 and G.0723.10 and ‘Onderzoeksfonds K.U. Leuven grant OT/10/050 (G.M.V.).

G.M.V. is a holder of the Glaxo Smith Kline (Belgium) Chair in respiratory pharmacology at the KULeuven. B.M.V., D.E.V.R., and L.J.D. are senior research fellows of the FWO.

4 Address correspondence to: Geert M. Verleden, M.G., Ph.D., Lung Transplantation Unit, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.


G.M.V., R.V., and S.E.V. investigated the database and wrote the manuscript; W.D.W. scored the CAT scans together with G.M.V.; S.I.D. and A.W.W. helped in screening the database and participated in the performance of the research; H.S. performed the statistical analysis; L.J.D., D.E.V. and B.M.V. participated in the care for the transplant patients and in the performance of the research.

Received 20 May 2011. Revision requested 13 June 2011.

Accepted 30 June 2011.

Bronchiolitis obliterans syndrome (BOS), defined as a persistent and obstructive pulmonary function decline after lung transplantation, remains the major cause of late mortality (1, 2). In recent years, different phenotypes of BOS have been described, one of these being neutrophilic reversible allograft dysfunction (NRAD), characterized by a progressive obstructive forced expiratory volume in 1 sec (FEV1) decline, neutrophilic airways inflammation, and at least 10% FEV1 reversibility with azithromycin treatment (3). Another such example is follicular bronchiolitis that is recognized as a specific entity of chronic obstructive loss in FEV1 (4, 5). Several authors also described a chronic restrictive pulmonary function decline in lung transplant patients, for instance in the upper lobe fibrosis syndrome (6) and in restrictive BOS (7). Recently, the Toronto group introduced restrictive allograft syndrome (RAS) to describe lung transplant patients with a persistent decline in FEV1 (>20% compared with the best postoperative values), characterized by a restrictive pulmonary function defect, which they defined as a decline in total lung capacity (TLC) more than 10%. The patients with RAS also displayed more interstitial opacities, ground glass opacities, upper lobe dominant fibrosis, and honeycombing on computer tomography (CAT) thorax than patients with BOS (8). Moreover, these RAS patients had a worse survival after diagnosis compared with patients with the classical BOS (8). As a consequence, BOS no longer describes all patients with persistent decline in pulmonary function, and some authors now prefer chronic lung allograft dysfunction (CLAD) as a broader entity (7–10), which could be defined as a persistent decline in FEV1 of more than 20%, independent of the type of pulmonary function defect, however, without another identifiable cause or confounding factor being present, analogous to the BOS definition (2). Because correct phenotyping of patients with CLAD seems important (for instance with regard to prognosis), this study aimed first to describe and phenotype a single-center population of transplant patients with CLAD and second, to identify risk factors for mortality after CLAD diagnosis in relation to these different phenotypes, including clinical parameters, radiologic presentation (CAT scan of the thorax with or without persistent interstitial infiltrates such as interstitial opacities, ground glass opacities, upper lobe dominant fibrosis, and honeycombing), and pulmonary function pattern.

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Between January 2002 and December 2009, 326 lung transplantations were performed. Our immunosuppressive protocol and classical follow-up procedure have been described previously (11). We excluded 19 early deaths (within 6 months after transplantation). None of these deaths were attributed to CLAD. Of the remaining 307 patients, 2 were not evaluable for CLAD, because of an inadequate technique to perform the pulmonary function test and 12 developed a more than 20% decline in FEV1, which was attributed to identifiable confounding factors (Fig. 1A). Finally, 293 patients with a mean age at transplantation of 49.2±13.5 years were included for further analysis, of whom 71 (24.2%) developed CLAD at a mean of 30.9±22.8 months (median 25, interquartile range [IQR] 11–46 months) after transplantation (Fig. 1A). There were 36 of 138 transplanted females (26.1%) and 35 of 155 males (22.6%; P=0.41). The mean follow-up of these 71 patients after transplantation was 49.2±26.9 months (median 48.0, IQR 4.5–69.5 months). Sixty patients were initially diagnosed with CLAD when their FEV1 was between 66% and 80%, 7 with the FEV1 between 51% and 65%, and 4 with the FEV1 less than or equal to 50% of the postoperative best. Of these 71 CLAD patients, 15 had been previously diagnosed with the NRAD phenotype of BOS, but normalized their FEV1 on azithromycin treatment (hence no longer qualifying as having BOS) and redeveloped CLAD during further azithromycin therapy. Twelve of these 15 patients had been included in the placebo arm of our recently published randomized azithromycin trial (11). The onset time of the second episode of CLAD was, therefore, regarded as the incident time of CLAD in this study. The patient characteristics are summarized in Table 1.





After diagnosis of CLAD, we found no difference in survival according to the underlying disease before transplantation (P=0.56), neither between single versus sequential single lung recipients (P=0.52) nor between patients on different immunosuppressive regimes. All but four patients were on azithromycin treatment, because NRAD had been previously diagnosed as stated earlier (n=15) or because azithromycin therapy was initiated when CLAD was diagnosed (n=52), which is a common practice in our center. However, none of these 52 patients experienced a sustained FEV1 response more than 10%, excluding NRAD (3). Of the 71 patients, 17 were switched from azathioprine to mycophenolate mofetil at diagnosis and 67 were already on tacrolimus treatment, 4 remained on cyclosporine treatment; 55 patients were additionally treated with an oral steroid taper when CLAD was diagnosed. There was no survival difference neither in the mycophenolate mofetil group (P=0.17) nor in the tacrolimus group (P=1.0).

A mean of 4.0±2.5 (range 1–13) pulmonary CAT scans was performed per patient from time of CLAD diagnosis to death or most recent follow-up visit (up to June 2010). Of the 71 patients, 22 patients had persistent parenchymal infiltrates on CAT scan (31%). After CLAD was diagnosed, a mean of 12.8±11.3 pulmonary function tests per patient was found. In 51 of 71 patients (72%), the pulmonary function remained obstructive, compatible with BOS, and 20 patients (28%) developed a restrictive pulmonary function, suggestive for RAS, of whom 17 (85%) also developed persistent parenchymal infiltrates on CAT scan, whereas this was only detected in 5 patients (9.8%) in the BOS group (Fig. 1B).

Of these 20 RAS patients, 15 were diagnosed based on persistent TLC decline of more than 10%, whereas in 5 not enough TLC data were available to comply with the RAS definition as outlined by Sato et al. (8). However, these five patients experienced a decline in FEV1 of more than 20% and a simultaneous decline in forced vital capacity (FVC), so that the FEV1:FVC ratio remained normal or even increased above normal, which is also compatible with a restrictive pulmonary function defect (12).

When we analyzed the cellular differentiation in the broncho alveolar lavage (BAL) fluid at diagnosis of CLAD, we found no significant differences between patients with RAS or BOS. The median BAL neutrophilia and lymphocytosis was 4.2% and 6.0% in RAS versus 12.2% and 6.2% in BOS patients (P=0.35 and 0.41, respectively).

The actuarial survival post-CLAD (n=71) is shown in Figure 2A (median 26 months). There was no clear survival difference between males and females (P=0.82); however, there was a significant survival difference between patients who developed early (within 24 months after transplantation, n=35) compared with late CLAD (n=36) with a median survival of 20 versus 39 months (P=0.038, Fig. 2B).



Patients with RAS had a significantly worse survival compared with the ones with BOS (median 8 vs. 35 months, P=0.001, Fig. 2C). When we compared post-CLAD survival according to the presence or absence of persistent parenchymal infiltrates on CAT scan, there was a significant difference with a median survival of 14 versus 35 months (P=0.0058; data not shown). Patients who had previously been diagnosed with NRAD before their current diagnosis of CLAD (n=15/71) had a significantly worse survival (median 11 vs. 35 months, P=0.0086, Fig. 2D).

In univariate cox regression, the previous development of NRAD and development of a restrictive pulmonary function pattern were both associated with a significantly worse survival, whereas the early development of CLAD and the development of persistent parenchymal infiltrates on CAT scan showed a strong trend for a worse survival. Gender, age, type of transplantation (single vs. sequential single), and immunosuppressive treatment were not significant. In multivariate analysis, including all parameters with a P value less than 0.1 in the univariate analysis, early development of CLAD, previous NRAD, and a restrictive pulmonary function pattern were correlated with a worse survival (P=0.0002 for the whole model; Table 2). If we included persistent parenchymal infiltrates on CAT scan in the multivariate regression instead of restrictive pulmonary function (both together is statistically not allowed because of the strong correlation between restrictive pulmonary function and persistent parenchymal infiltrates on CAT), the model remained significant (P=0.0006), with persistent parenchymal infiltrates on CAT having a hazard ratio of 3.35 (95% confidence interval 1.46–7.68, P=0.0043) for mortality.



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In this retrospective single-center study, we corroborated the existence of different phenotypes of CLAD, and we further analyzed the risk factors for mortality after diagnosis. First, we found that 51 of 71 CLAD patients (almost 72%) developed an obstructive pulmonary function, which is compatible with the current definition of BOS (2), whereas 20 (28%) became restrictive, which is rather compatible with RAS (8). Most of the patients with a restrictive pulmonary function also developed persistent parenchymal infiltrates on CAT scan (17/20), whereas only 5 of 51 patients with an obstructive pulmonary function developed persistent parenchymal infiltrates on CAT scan. Despite these CAT scan abnormalities, these latter patients did not meet the TLC criteria for restriction as outlined by Sato et al. (8), which may be explained by the fact that in the initial phase of CLAD, they developed the BOS phenotype, whereas only later on during the evolution of CLAD, persistent parenchymal infiltrates appeared on CAT scan. This suggests that if follow-up had been longer, they might have qualified for RAS instead of BOS. This phenomenon was also reported in the study by Sato et al. (8). What it specifically means for survival remains unanswered as this group of five patients is too small to perform statistical comparisons.

In contrast to Sato et al. (8), this article differs in at least two ways: (1) in addition to a TLC decline of more than 10% to define pulmonary restriction, we have also used the FEV1:FVC ratio, which is indeed an accepted parameter to describe restrictive pulmonary function (11); (2) in our series, we also included patients with a single lung transplantation, which were deliberately excluded in the analysis by Sato et al. This may also explain why we had more patients with persistent parenchymal infiltrates in the BOS group, especially when a single lung transplantation was performed for emphysema. Single lung transplant patients with confounding factors that might have affected the pulmonary function pattern, such as hyperinflation or progressive interstitial lung disease of the native lung, were excluded for further analysis (Fig. 1A).

The present data confirm the data of the Toronto group, in which the concept of RAS was introduced as a new CLAD phenotype. In their series of 156 patients with CLAD, 47 (30%) developed the RAS phenotype, which is in line with the 28% in the current series. Moreover, we confirmed the worse survival in the RAS patients, which indeed significantly differed from the survival in patients with the classical BOS phenotype (median of 8 vs. 35 months).

Woodrow et al. (7) recently demonstrated that 35% of their patients with CLAD developed persistent parenchymal infiltrates on CAT scan, which they called nonspecific BOS, without giving further specification as to their pulmonary function. In their series, however, there was no survival difference, which may be explained by their use of different criteria to define persistent infiltrates as patients with pleural effusions were also included in this analysis and by the fact that their cohort was rather small (7).

As a consequence, development of a nonobstructive pulmonary function decline after lung transplantation seems to be a consistent finding in different series, and therefore, it seems more appropriate to use other terminology besides BOS, which may better reflect all patterns of persistent decline in FEV1. In that case, CLAD may be the preferred terminology, whereas BOS and RAS may then be a subdivision of CLAD, not only characterized by the type of pulmonary function decline but also characterized by CAT scan findings, mostly demonstrating persistent parenchymatous involvement in the RAS phenotype. Whether these parenchymatous changes are consistent with chronic rejection remains to be further investigated, although Sato et al. could demonstrate the presence of diffuse alveolar damage and extensive fibrosis in the alveolar interstitium, visceral pleura, and interlobular septa with or without scattered bronchiolitis obliterans lesions, which suggests that chronic rejection may indeed be involved in the RAS phenotype (8). Martinu et al. (13), investigating the pathology of explant lungs in patients who were retransplanted for BOS, found at least 2 of 12 patients with extensive interstitial changes with septal widening. Burton et al. (14) also found an increased prevalence of cryptogenic organizing pneumonia and interstitial fibrosis in their transbronchial biopsy study. These findings do not prove that chronic interstitial changes are related to chronic rejection, but at least they are suggestive for it. In our patient group, transbronchial biopsies did not specifically contribute to the differential diagnosis between BOS and RAS, as they were mostly nonspecific and were rather used to exclude acute rejection and infection. Also, BAL cell differentiation was not different between these two phenotypes, whereas for instance in the BOS subphenotypes, NRAD, and fybrotic bronchiolitis obliterans syndrome, this is indeed clearly different (3, 10).

Another, rather unexpected result from our study was the fact that previous development of NRAD seemed to be a risk factor for mortality after later CLAD diagnosis. NRAD has indeed been described as a specific phenotype of BOS, characterized by an obstructive FEV1 decline, neutrophilic BAL, and more than 10% FEV1 reversibility on azithromycin treatment (3). In this study, although most of the patients were started (52/71) or were already on azithromycin for a previous NRAD (15/71), none of them had a sustained FEV1 response more than 10% after CLAD was diagnosed, excluding current NRAD as a potential bias. It has recently been shown that some 30% of the patients who were previously diagnosed with the NRAD phenotype of BOS will redevelop CLAD during further follow-up despite still being treated with azithromycin (15, 16). Although persistent BAL neutrophilia is a recognized risk factor for the development of BOS (17–19), it is now also accepted that BAL neutrophilia (as in NRAD) can be adequately treated with macrolides (20). This may favor an early-onset preventive treatment of NRAD with macrolides. In fact, in a recently published double-blind, placebo-controlled trial with azithromycin, we showed that the BOS prevalence at 2 years after transplantation was indeed significantly lower in the active treatment group, which was mainly due to the prevention of the development of NRAD (11). Whether this approach may lower the prevalence of CLAD afterward remains to be investigated.

Some of our findings are in line with other published data such as the mean time to onset of CLAD (31 months) (21), the 5-year survival after diagnosis of CLAD (26% in Duke [20] and 32% in this study), and no influence of gender (21), which may contrast with the data of Lama et al. (22) who showed that females with BOS had a worse lung function trajectory (although the effect on survival was not established).

Half of our patients developed an early-onset CLAD (i.e., within 24 months after transplantation), with an inherent worse prognosis that corroborates previous data (20–22). Because most of our patients (84.5%) were diagnosed with CLAD in stage 1 disease (i.e., >20% decline in FEV1), we found no difference in survival of higher CLAD stages at diagnosis, although it is accepted that patients with a fast decline in FEV1 have indeed a worse survival, whether this develops early or late after transplantation (21, 23, 24).

In conclusion, our study clearly confirms the existence of the RAS phenotype, which occurred in approximately 28% of patients with CLAD after lung transplantation and has an inherent worse prognosis compared with patients who develop BOS. Also, early CLAD (<24 months after transplantation) and previous NRAD were identified as other predictors for a worse survival after CLAD diagnosis. What this means in terms of prophylactic treatment with for instance azithromycin remains to be further investigated.

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We retrospectively investigated the medical records of all patients with a first lung transplantation in our center between January 2002 and December 2009. We choose these dates because our follow-up database started in 2002 and because we wanted to have an individual follow-up period of at least 6 months.

The pulmonary function of these patients was longitudinally evaluated at several time points after transplantation (spirometry 1–2 times per week during the first 3 months, and then at least once per month for the first postoperative year, thereafter at least once every 3 months). Full pulmonary function tests using body plethysmography was performed at least twice per year (from 2005 on). At the same time, patients were instructed to use a home spirometry device on a daily basis and to contact the transplant center in case the FEV1 decreased by more than 10% at two consecutive occasions. Patients with a persistent FEV1 decline of more than 20% were defined as having CLAD and were included in the study population. This FEV1 decline was calculated as a 20% drop from the mean of the two best postoperative values, with at least 3 weeks in between the two measurements, without another identifiable cause for this decline (2). The CLAD population was then subdivided according to the development of an obstructive (BOS) or restrictive pulmonary function pattern (RAS). Similar to Sato et al. (8), we defined a restrictive pulmonary function as a decline in TLC of at least 10% from baseline (8), but in case not enough TLC measurements were available, a FEV1:FVC index that remained normal or increased above normal with an FVC decline of at least 20% from baseline was also considered restrictive, whereas a FEV1:FVC index of less than 0.7 was considered obstructive (12). Pulmonary function tests were performed according to the American Thoracic Society guidelines on a Masterscreen IOS system or a Masterscreen PFT system (Jaeger, Acertys, Aartselaar, Belgium) (25).

All consecutive pulmonary CAT scans from the time of diagnosis of CLAD were evaluated by G.M.V. and W.D.W. until consensus was reached and further categorized according to the presence or absence of persistent (at least 3 months) parenchymal involvement (such as interstitial opacities, ground glass opacities, upper lobe dominant fibrosis, and honeycombing). The radiologic findings on the last performed CAT scan after CLAD diagnosis were used for final analysis. CAT scans were performed using four different scanners: Siemens Sensation 16, Siemens Sensation 64, Siemens Definition Flash, or Philips Brilliance 64. A spiral computed tomography scan was performed during inspiration and full expiration, with settings as follows: 120 kV, 140 mAs+dose modulation with 5- and 1-mm sections for inspiration and 120 kV, 150 mAs, 1-mm sections and feed=30 mm for expiration.

The local hospitals Ethics Committee approved this retrospective study. Statistical analysis was performed using GraphPad PRISM version 4.0 (GraphPad, San Diego, CA) and SAS (SAS software, version 9.1, SAS Institute, Cary, NC) for Mann-Whitney U test and Spearman rank correlations. Contingency tables were constructed using chi-square test or Fisher's exact test where appropriate. Kaplan-Meier survival curves were analyzed using the log-rank test. Patient who were retransplanted because of CLAD (n=7) were considered dead at the time of retransplantation.

Cox proportional hazard survival regression analysis (P<0.1 entry and P>0.1 removal) was used to estimate hazard ratios and their 95% confidence intervals of several parameters possibly predicting post-CLAD survival: gender, pretransplant diagnosis, single versus sequential single lung transplantation, postoperative day of CLAD diagnosis (early vs. late), parenchymatous infiltrates involvement on CAT scan findings, previous development of NRAD, immunosuppressive regimen, and pulmonary function pattern (obstructive vs. restrictive). Data are presented as mean±standard deviation or median with IQR; P less than 0.05 was considered as significant.

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Lung transplantation; CLAD; BOS; RAS; Phenotyping

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