Diagnostic value of follow-up transbronchial lung biopsy after lung rejection

Although transbronchial lung biopsy (TBBx) is widely acknowledged as the "g old standard" for diagnosis of acute rejection, controversy exists regardin g the need to perform follow-up procedures. Over a 5-yr period, we performe d 1,142 TBBx of which 173 were follow-up TBBx in 99 patients with pulmonary allograft rejection greater than or equal to International Society for Hea rt and Lung Transplantation (ISHLT) grade A(2) on initial TBBx. Rejection o n the previous 173 TBBx was associated with lymphocytic bronchiolitis/bronc hitis (LBB) greater than or equal to ISHILT grade B-2 in 82 patients and wi th cytomegalovirus (CMV) pneumonitis in 16 patients. Persistent rejection ( greater than or equal to A(2) was observed in 45 of 173 (26%) follow-up TBB x. Persistent B grade rejection (greater than or equal to B-2) was present in 28 patients whereas new B grade rejection developed in 11 patients with greater than or equal to A(2) grade rejection. Rejection greater than or eq ual to B-2 was significantly (p < 0.05) associated with rejection greater t han or equal to A(2). Fifteen follow-up TBBx showed new B grade rejection w ithout signs of greater than or equal to A(2) rejection. A new diagnosis of CMV pneumonitis was made in 33 of 173 (19%). CMV pneumonitis occurred in 3 5 follow-up TBBx, four associated with greater than or equal to A(2) reject ion and eight with greater than or equal to B-2 rejection. The overall inci dence of bronchiolitis obliterans syndrome (BOS) in both groups was similar . Patients with persistent rejection on follow-up TBBx developed BOS at a m edian of 1.3 yr and median of 2.0 yr (p = not significant [NS]) posttranspl antation. The practice of follow-up TBBx after rejection within 2 yr posttr ansplant is clinically useful as it provides valuable diagnostic informatio n.