Clinical lung and heart/lung transplantation
Success of lung transplantation without surveillance bronchoscopy

https://doi.org/10.1016/S1053-2498(01)00389-8Get rights and content

Abstract

Background:

No current evidence demonstrates improved survival or decreased rate of bronchiolitis obliterans syndrome (BOS) despite regularly scheduled fiberoptic bronchoscopy (FOB) with transbronchial biopsy and bronchoalveolar lavage (TBB/BAL) after lung transplantation. Reduced lung function detected with spirometry or oximetry in symptomatic and asymptomatic lung allograft recipients (LARs) may be a more appropriate indication for bronchoscopic sampling.

Hypothesis:

Clinically indicated TBB/BAL without routine invasive surveillance sampling of the transplanted lung does not decrease survival or increase the rate of BOS in LARs.

Methods:

We reviewed 91 consecutive LARs transplanted at Ochsner Clinic between January 1995 and December 1999. Clinical indications for FOB with TBB/BAL include 10% decline in forced expiratory volume in 1 second below baseline; 20% decrease in forced expiratory flow rate between 25% and 75% of the forced vital capacity; or unexplained respiratory symptoms, signs, or fever. Along with demographic and clinical data, 1-year and 3-year survival rates for these 91 LARs were compared with 5,430 LARs from the International Society for Heart and Lung Transplantation (ISHLT) Registry transplanted during the same 60-month period. Ten of the 91 patients did not survive to hospital discharge after transplantation. We divided the remaining 81 LARs into 2 subsets: Group A patients (n = 43) underwent zero to 1 TBB/BAL and Group B patients (n = 38) required more than 1 procedure. Demographic data, rejection, infection, and incidence of BOS were compared between groups.

Results:

The 1-year and 3-year survival rates in the Ochsner LAR cohort were 85% and 73%, respectively, vs 72% and 57% in the ISHLT cohort p < 0.01. The relative risks of death in the Ochsner group at 1- and 3-years were 0.56 (0.35–0.91) and 0.66 (0.48–0.92), respectively, p < 0.05. The median (range) follow-up was 910 days (60–1,886) for Group A and 961 days (105–1,883) for Group B, p = not significant. We observed twice as many patients with cystic fibrosis and twice as many pneumonia episodes in Group B. The rate of acute rejection in each group was not statistically different. The cumulative incidence of BOS was increased in Group B at 1 year and at 3 years (5% and 56%) when compared with Group A (3% and 13%), p < 0.01.

Conclusion:

Based on the findings from this observational, single-institution study, clinically indicated TBB/BAL without routine surveillance sampling of the lung allograft is unlikely to pose greater risk than does regularly scheduled bronchoscopy after lung transplantation.

Section snippets

Group comparisons

Between January 1995 and December 1999, a total of 91 consecutive patients underwent single (n = 36) or bilateral sequential (n = 55) LT at Ochsner Clinic. Pre-operative and post-operative variables were abstracted for analysis. The Oschner Clinic (OC) cohort was then compared with 5,430 patients transplanted contemporaneously as identified from the ISHLT Registry data, obtained with permission. Basic demographic data, underlying diseases, and survival curves were compared between the 2 groups.

Results

Table I shows pre-operative and post-operative characteristics of the Ochsner group. Table II illustrates demographic characteristics and pre-transplantation diagnoses of OC and ISHLT groups. In addition to a larger proportion of females and African Americans, cystic fibrosis and idiopathic pulmonary fibrosis comprised a greater percentage of LARs in the OC cohort when compared with the ISHLT cohort. In contrast, pulmonary hypertension was observed in a larger percentage of ISHLT LARs. Also of

Discussion

Transbronchial biopsy is considered the gold standard for determining the cause of respiratory decompensation in LARs. When clinical derangements are apparent, the ability of FOB with TBB/BAL to diagnose infection or rejection ranges between 69% and 83%.15, 16 This procedure’s sensitivity and specificity for acute rejection has been reported to be high as 94% and 100% in symptomatic LARs,1 although the diagnostic yield appears to be highly variable between institutions. At least 5 adequate TBB

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