OBLITERATIVE BRONCHIOLITIS AFTER LUNG AND HEART-LUNG TRANSPLANTATION - AN ANALYSIS OF RISK-FACTORS AND MANAGEMENT

With a prevalence of 34% (55/162 at-risk recipients) and a mortality o f 25% (14/55 affected recipients), obliterative bronchiolitis is the m ost significant long-term complication after pulmonary transplantation . Because of its importance, we examined donor-recipient characteristi cs and antecedent clinical events to identify factors associated with development of obliterative bronchiolitis, which might be eliminated o r modified to decrease its prevalence. We also compared treatment outc ome between recipients whose diagnosis was made early by surveillance transbronchial lung biopsy before symptoms or decline in pulmonary fun ction were present versus recipients whose diagnosis was made later wh en symptoms or declines in pulmonary function were present. Postoperat ive airway ischemia, an episode of moderate or severe acute rejection (grade III/IV), three or more episodes of histologic grade II (or grea ter) acute rejection, and cytomegalovirus disease were risk factors fo r development of obliterative bronchiolitis. Recipients with obliterat ive bronchiolitis detected in the preclinical stage were significantly more likely to be in remission than recipients who had clinical disea se at the time of diagnosis: 81% (13/15) versus 33% (13/40); p < 0.05. These results indicate that acute rejection is the most significant r isk factor for development of obliterative bronchiolitis and that obli terative bronchiolitis responds to treatment with augmented immunosupp ression when it is detected early by surveillance transbronchial biops y.