Persistent increases of BAL neutrophils as a predictor of mortality following lung transplant

Study objectives: To evaluate whether findings from surveillance bronchosco py predict survival following lung transplantation. Design: Retrospective review and analysis of 498 bronchoscopies with transb ronchial biopsy (TBB) and BAL performed in 34 patients after lung transplan tation. Setting: University-based, tertiary referral medical center, Patients: Thirty-four patients after lung transplantation, The mean age at transplantation was 49 +/- 9 years; 20 (59%) were female. Twenty-four (71%) underwent single and 10 (29%) underwent bilateral lung transplantation. Th e most common pretransplantation diagnostic groups were emphysema/COPD with out concomitant alpha(1)-antiprotease deficiency (n = 13) and other obstruc tive disease processes (n = 10). Interventions: Over follow-up, subjects underwent multiple bronchoscopies w ith TBB and BAL, The median number per subject was 15 (25 to 75% range 13 t o 17). Measurements and results: We calculated the overall median BAL WBCs and med ian percent neutrophils (polymorphonuclear leukocytes [PMNs]) among all of the BALs performed for each subject. We then calculated the mean a SD of th ose median values. We used Cox proportionate hazards to assess mortality ri sk. The median overall follow-up observation period for the cohort was 560 days. There were 11 deaths during this period. Twenty-four subjects (71%) h ad acute rejection (AR) grades 2 to 4 (mild to severe), and nine (27%) had obliterative bronchiolitis (OB) diagnosed by TBB at any point. The mean val ue for BAL WBCs was 366 +/- 145 x 10(3) per milliliter; for percentage PMNs , the mean was 7 a 10%. Adjusting for age, gender, single vs bilateral lung transplantation, pretransplantation diagnostic group, presence of AR, pres ence of OB, BAL WBC concentration, and lymphocyte CD4/CD8 ratio, PMN pet-ce nt was a significant predictor of mortality (p = 0.02). Conclusions: Ongoing inflammation manifested by an increased percentage PMN s over repeated bronchoscopies predicts mortality following lung transplant ation. Biopsy data alone may be insufficient to identify posttransplantatio n patients at risk of poor outcome.