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Masaaki Sato, MD, PhD, David M. Hwang, MD, PhD, Thomas K

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Presentation on theme: "Masaaki Sato, MD, PhD, David M. Hwang, MD, PhD, Thomas K"— Presentation transcript:

1 Progression pattern of restrictive allograft syndrome after lung transplantation 
Masaaki Sato, MD, PhD, David M. Hwang, MD, PhD, Thomas K. Waddell, MD, MSc, Lianne G. Singer, MD, Shaf Keshavjee, MD, MSc  The Journal of Heart and Lung Transplantation  Volume 32, Issue 1, Pages (January 2013) DOI: /j.healun Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

2 Figure 1 Acute exacerbation and definition of clinical course during the period of study. The first change in the slope of FEV1 after the initiation of acute exacerbation was taken as the end of the acute exacerbation episode. Clinical courses after an episode of acute exacerbation were classified based on post-exacerbation FEV1 changes. The Journal of Heart and Lung Transplantation  , 23-30DOI: ( /j.healun ) Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

3 Figure 2 Changes in CT scan findings at the time of acute exacerbation. CT scans at the time of acute exacerbation were available and compared with those before acute exacerbation in 43 episodes of 23 patients. Acute exacerbation typically showed GGO, more often diffuse than patchy. Appearance or aggravation of consolidation was also a relatively common finding, whereas appearance or aggravation of interstitial reticular shadow or traction bronchiectasis was observed less frequently at the time of acute exacerbation. The Journal of Heart and Lung Transplantation  , 23-30DOI: ( /j.healun ) Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

4 Figure 3 Changes in CT scan findings during intervals between acute exacerbations. During 25 acute exacerbation intervals in 18 patients, GGO usually showed improvement on CT scan, whereas other characteristics (interstitial reticular shadow, consolidation and traction bronchiectasis) tended to worsen. Not applicable (n/a) indicates that the type of abnormality did not exist before the interval and did not appear during the interval. The Journal of Heart and Lung Transplantation  , 23-30DOI: ( /j.healun ) Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

5 Figure 4 A representative case of RAS after lung transplantation: Case 1. (A) Post-transplant PFT changes of a 62-year-old man who received cadaveric bilateral lung transplantation for COPD. (B)–(G) Chest CT scan of the same patient. (B) Post-transplant day 179, when the patient was stable. (C) Post-transplant day 361, when the patient was stabilized to some extent but still undergoing continuous functional deterioration. (D) Post-transplant day 760, when the patient was recovering from the second exacerbation. (E) Post-transplant day 284, when the patient underwent the first episode of acute exacerbation. DAD was detected in a transbronchial biopsy. Steroid pulse with empirical antibiotics treatment was conducted. Cyclosporine was switched to tacrolimus. (F) Post-transplant day 468, when the patient had the second episode of acute exacerbation. Once again, DAD was detected in a transbronchial biopsy. Azithromycin was initiated. (G) Post-transplant day 889, when the patient had the third episode of acute exacerbation. Arrows: time-point at which the CT scan was taken; white arrows: acute exacerbation. CsA, cyclosporine; FK, FK 506 (tacrolimus). The Journal of Heart and Lung Transplantation  , 23-30DOI: ( /j.healun ) Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

6 Figure 5 A representative case of RAS after lung transplantation: Case 2. (A) Post-transplant PFT changes in a 28-year-old man with cystic fibrosis who received cadaveric bilateral lung transplantation. (B)–(G) Chest CT scan of the same patient. (B) Post-transplant day 215, when the patient was stable. (C) Post-transplant day 535, when the patient was recovering from the first episode of acute exacerbation. After steroid pulse and increased prednisone, function partially recovered with clearance of GGO, although interlobular septal thickening, interstitial reticular shadow and consolidation remained. (D) Post-transplant day 1,131, when the patient was recovering from the second exacerbation. Although his condition was relatively stable for 2 years after the second episode, the patient's CT scan showed gradual increases in interlobular septal thickening, interstitial reticular shadow and consolidation. He was listed for retransplantation. (E) Post-transplant day 374, when the patient underwent the first episode of acute exacerbation. CT scan showed extensive bilateral GGO, bilateral pneumothorax and pneumomediastinum. Transbronchial biopsies demonstrated DAD without evident rejection or infection. (F) Post-transplant day 817, when the patient had the second episode of acute exacerbation. CT scan showed reappearance of diffuse GGO with worsening interstitial shadows. (G) Post-transplant day 1,333, when the patient had the third episode of acute exacerbation. FEV1 declined further. CT scan showed further volume loss in the transplanted lungs, extensive GGO, and worsening consolidation and interlobular septal thickening. Arrows: time-point at which CT scan was taken; white arrows: acute exacerbation. The Journal of Heart and Lung Transplantation  , 23-30DOI: ( /j.healun ) Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

7 Figure 6 Representative case of RAS after lung transplantation: Case 3. (A) Post-transplant PFT changes in a 52-year-old man who received bilateral lung transplantation for IPF. (B)–(G) Chest CT scans of the same patient. (B) Post-transplant day 280, when the patient was stable. (C) 401 days post-transplant. (D) Post-transplant day 853, when the patient had the second episode of acute exacerbation. CT scan showed diffuse bilateral GGO, interstitial septal thickening and consolidation. (E) Post-transplant day 364, when the patient underwent the first episode of acute exacerbation. CT scan showed extensive GGO, reticular shadow, confluent airspace opacities and architectural distortion. Transbronchial biopsies showed DAD without rejection or infection. His general condition and PFTs and CT scans showed gradual improvement over the next 16 months. (F) 735 days post-transplant. (G) 883 days post-transplant. Although CT scan showed mild improvement in GGO 1 month later, his condition continued to deteriorate, and he died about 1 month after the second episode of acute exacerbation. Arrows: time-point at which the CT scan was taken; white arrows: acute exacerbation. The Journal of Heart and Lung Transplantation  , 23-30DOI: ( /j.healun ) Copyright © 2013 International Society for Heart and Lung Transplantation Terms and Conditions

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