Surveillance transbronchial lung biopsies: Implication for survival after lung transplantation

Objectives: We wished to determine whether early rejection after lung trans plantation as assessed by surveillance transbronchial biopsy predicts for s urvival. Methods: Between 1990 and 1997, 96 consecutive patients had lung t ransplantation: 89 had a minimum 1-month followup. For 71 consecutive patie nts we have 1-year follow-up and for 69 patients we have the results of the first 3 biopsies. Cytomegalovirus status, bronchiolitis obliterans prevale nce, and use of total lymphoid irradiation are noted. Biopsies were done at 1 week and 1, 3, and 6 months, Standard immunosuppression consisted of ind uction antilymphocyte globulin and high-dose methylprednisolone induction f or 1 week and standard maintenance triple therapy, Acute rejection treatmen t was with pulse methylprednisolone. Bronchiolitis obliterans syndrome was treated with total lymphoid irradiation and a change to tacrolimus and myco phenolate, Blinded grading using international Society for Heart and Lung T ransplantation classification was done retrospectively. Results: Survival a t 1 month and 1, 2, and 3 years for the 96-patient cohort with 1-year follo w-up was 93%, 74%, 62%, and 56%. Survival was not significantly different f or subsets with rejection on any combination of the first 3 biopsies (1/3, 2/3, 3/3) or absence of rejection on the first 3 biopsies. Ninety-one posit ive biopsy results were graded. Eighteen of 71 patients had one or more mod erate or severe rejection episodes without survival difference relative to the others. There was no statistically significant association between acut e rejection on the first 3 surveillance biopsy results and bronchiolitis ob literans, Conclusions: Intensive induction and maintenance immunotherapy wi th surveillance transbronchial biopsies and aggressive treatment of acute r ejection is associated with a survival similar to that of patients without early acute rejection. This regimen appears to uncouple the association bet ween early acute rejection and bronchiolitis obliterans, Further study may elucidate this mechanism.