13Long-term outcomes and management of lung transplant recipients
Section snippets
Acute cellular rejection (T-Lymphocyte rejection)
Acute cellular rejection (ACR) is the predominant type of rejection in lung transplant that affects the vasculature and small airways, thus potentially resulting in acute graft dysfunction and failure over time. The key distinction between acute and chronic rejection is the presence of irreversible airway fibrosis. ACR is an important risk factor for the development of bronchiolitis obliterans syndrome (BOS), and its severity, particularly the pathologic evidence of lymphocytic bronchiolitis,
Antibody-mediated rejection (humoral rejection)
Hyperacute rejection is a form of rejection that occurs rapidly after transplantation and is caused by preformed anti-HLA antibodies, and it is associated with an extremely high mortality. Fortunately, given the advances in HLA screening, the incidence of hyperacute rejection after lung transplantation is now extremely rare. The other form of humoral rejection, antibody-mediated rejection (AMR), is associated with four specific factors: (1) donor-specific anti-HLA antibodies (DSAs), (2)
Chronic rejection
Lung transplantation remains the only viable treatment option for patients with end-stage lung disease; however, long-term survival of these patients remains limited because of chronic lung allograft dysfunction, with BOS as the leading cause of late mortality and morbidity. Bronchiolitis obliterans is a small airway disease, mofetil triggered by an insult to small airway epithelial and subepithelial cells with the subsequent formation of excessive fibrosis and airway constriction. Ultimately,
Viral infections
Infectious complications remain a significant cause of morbidity and mortality in lung transplant recipients. Lung transplant recipients are at increased risk of infection for multiple reasons, including continuous exposure of the allograft to environmental microorganisms, denervation of the lung resulting in impaired cough reflex, dysfunctional mucociliary clearance, impaired lymphatic drainage, and immunosuppression.
Several viral infections have been associated with poor long-term outcomes in
Postlung transplantation medical complications
Patients with end-stage lung disease waiting for a transplant have varying significant comorbidities, which are typically chronic in nature. These comorbidities require ongoing management and may be exacerbated posttransplant, potentially resulting in poor quality of life and shortened posttransplant survival.
Immunosuppressive medications contribute to cardiovascular comorbidities such as hyperlipidemia, diabetes, hypertension, and renal disease. Coronary artery disease is accelerated in
Long-term outcomes of lung transplantation
Advancements in surgical techniques and immunosuppression have resulted in improved survival outcomes in lung recipients. The survival of lung recipients is lower than that of other solid organ transplant recipients; the median survival after lung transplantation is 5.8 years, compared to a 70% 5-year survival after heart transplantation [Fig. 1] [66].
Survival, functional status, and quality of life are the leading measures of posttransplant outcomes. High-volume transplant centers on average
Conclusion
Our understanding of ACR remains a work in progress and requires an ongoing collaborative effort between lung transplant centers across the world, to gain a better understanding of ACR pathogenesis and diagnostics. ACR remains an important cause of early graft failure, and it is an important risk factor for CLAD, ultimately affecting long-term outcomes.
Despite advances in immunotherapy, chronic rejection continues to limit long-term survival in lung transplant recipients and exacerbate existing
Conflict of interest statement
None.
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