TREATMENT OF PRESUMED AND PROVEN ACUTE REJECTION FOLLOWING 6 MONTHS OF LUNG-TRANSPLANT SURVIVAL

The gold standard for the diagnosis and subsequent treatment of acute rejection of lung allografts is the demonstration of rejection on tran sbronchial biopsy specimens. However, treatment may be initiated in th e case of a compatible clinical scenario in the absence of definitive histologic documentation. In the Toronto Lung Transplant Program, we h ave treated patients with a decline in FEV(1) and no evidence of infec tion with augmented systemic steroids for a presumed diagnosis of reje ction. We retrospectively reviewed all episodes of acute rejection tha t occurred beyond 6 mo after transplant where treatment with augmented steroids had been initiated. A total of 72 treatments with augmented steroids were initiated in 45 patients who underwent 47 transplant pro cedures. FEV(1) showed at least a 10% improvement following steroids i n 14 of 72 (19%). FEV(1) continued to decline by at least 10% in 32 of 72 (44%). Changes in FEV(1) between +10 and -10% occurred in 26 of 72 (36%); of those episodes, 19 showed a decline of < 10%. Histologic ev idence of at least grade II rejection was documented in only 16 cases. In those cases, FEV(1) improved by at least 10% in 7 of 16 (44%), whe reas it declined by at least 10% in 4 of 16 (25%). Spirometric evidenc e of bronchiolitis obliterans syndrome developed within 3 mo of the tr eated rejection episode in at least 20 of 47 transplants (43%). We con clude that treatment with augmented systemic steroids for presumed and histologically proven acute rejection beyond 6 mo after transplant is often ineffective in improving spirometry.