Bronchiolitis obliterans after human lung transplantation
Bronchiolitis obliterans after human lung transplantation
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DOI：
10.1164/rccm.200201-003pp
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发表时间：
2002-08-15
影响因子：
24.7
通讯作者：
Hertz, MI
中科院分区：
文献类型：
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作者：
Estenne, M;Hertz, MI
在过去的十年中，手术技术、肺保护、免疫抑制和缺血再灌注损伤和感染管理的改进有助于将肺移植后1年患者生存率提高至70-80%（1）。然而，长期生存受到闭塞性细支气管炎的威胁，闭塞性细支气管炎被认为是慢性同种异体移植排斥的一种形式。肺移植后闭塞性细支气管炎于1984年首次在斯坦福大学的心肺移植受者中报道，这些受者表现出FEV 1的进行性下降（2）。这些患者的肺活检显示由纤维粘液样肉芽组织组成的腔内息肉和致密的粘膜下嗜酸性瘢痕斑块。这些病变阻塞小气道，造成进行性气流阻塞，常伴有反复下呼吸道感染。闭塞性细支气管炎及其临床相关的闭塞性细支气管炎综合征影响移植后存活5年的患者的50-60%（3）。在大多数患者中，闭塞性细支气管炎是一个渐进的过程，对增强的免疫抑制反应不佳，并且在术后第三年后发生的所有死亡中占30%以上（1）。闭塞性细支气管炎发作后5年的存活率仅为30- 40%，而有闭塞性细支气管炎的患者移植后5年的存活率比无闭塞性细支气管炎的患者低20-40%（4）。在这篇综述中，我们提出了目前关于移植后闭塞性细支气管炎的概念，包括：（1）最近更新的闭塞性细支气管炎综合征（BOS）的分类系统，（2）关于其发病机制和危险因素的当前概念的概述，（3）可能有助于早期检测的潜在替代标志物，以及（4）这种毁灭性并发症的管理方法。
Over the last decade, improvements in surgical techniques, lung preservation, immunosuppression, and management of ischemia–reperfusion injury and infections have contributed to increase the 1-year patient survival after lung transplantation to 70–80%(1). However, long-term survival is threatened by bronchiolitis obliterans, which is thought to be a form of chronic allograft rejection. Bronchiolitis obliterans after lung transplantation was first described in 1984 at Stanford University in heart–lung transplant recipients who showed a progressive decline in FEV1 (2). Lung biopsies from these patients showed intraluminal polyps comprised of fibromyxoid granulation tissue and plaques of dense submucosal eosinophilic scar. Obliteration of the small airways by these lesions produces progressive airflow obstruction, often accompanied by recurrent lower respiratory tract infection. Bronchiolitis obliterans, and its clinical correlate bronchiolitis obliterans syndrome, affect up to 50–60% of patients who survive 5 years after transplantation (3). In most patients, bronchiolitis obliterans is a progressive process that responds poorly to augmented immunosuppression, and it accounts for more than 30% of all deaths occurring after the third postoperative year (1). Survival at 5 years after the onset of bronchiolitis obliterans is only 30–40%, and survival at 5 years after transplantation is 20–40% lower in patients with than in patients without bronchiolitis obliterans (4). In this review, we present current concepts regarding post-transplant bronchiolitis obliterans, including:(1) the recently updated classification system for bronchiolitis obliterans syndrome (BOS),(2) an overview of current concepts regarding its pathogenesis and risk factors,(3) potential surrogate markers that may contribute to early detection, and (4) approaches to the management of this devastating complication.