Adjuvant treatment of refractory lung transplant rejection with extracorporeal photopheresis

Background: Extracorporeal photopheresis is an immunomodulatory technique i n which a patient's leukocytes are exposed to ultraviolet-A light after pre treatment with 8-methoxypsoralen (methoxsalen). There have been few reports describing the use of extracorporeal photopheresis in lung transplant reci pients. Methods: We reviewed our experience using extracorporeal photophere sis in 8 lung transplant recipients since 1992. All 8 patients had progress ively decreasing graft function and 7 were in bronchiolitis obliterans synd rome grade 3 before the initiation of photopheresis. One patient had underg one a second transplant operation for obliterative bronchiolitis. Two patie nts had a pretransplantation diagnosis off chronic obstructive pulmonary di sease, 1 alpha(1)-antitrypsin deficiency, 1 cystic fibrosis, 1 bronchiectas is, 1 idiopathic pulmonary fibrosis, and 2 primary pulmonary hypertension. Before refractory rejection developed, all patients had been treated with 3 -drug immunosuppression and anti-T-cell therapy. The median time from trans plantation to the start of extracorporeal photopheresis was 16.5 months and the median number of treatments was 6, Results: The condition of 5 of 8 pa tients subjectively improved after extracorporeal photopheresis therapy, In these 5 patients photopheresis was associated with stabilization of the fo rced expiratory volume in 1 second. In 2 patients there was histologic reve rsal of rejection after photopheresis, With a median follow-up of 36 months , 7 patients are alive and well. Three patients required retransplantation at a median of 21 months after completion of the treatments. Four patients have remained in stable condition after photopheresis. There were no compli cations related to extracorporeal photopheresis. Conclusion: We believe tha t this treatment is a safe option for patients with refractory lung allogra ft rejection when increased immunosuppression is contraindicated or ineffec tive.