- Email: [email protected]
Heterogeneity and reversal of bronchiolitis obliterans syndrome
The Journal of Heart and Lung Transplantation Volume 18, Number 1
Abstracts
Three groups were identified. Group 1: 3%@=2)tmdewent ClX prior mean age at CTX 7 yrs., age at menarche for 1 subject was 12.5 yrs while the second at 16 yrs never started menses. Group 2: 42%@=38)were menstruating prior to ClX. Of these, 58%@=22) resumed pre CTX cycles within the first yr. following CTX, while 16%(n=6) resumed menses 1 yr. after CTX When compared to age-matched controls, statistical differences were not found for cycle lengtha, duration of flow or regularity; 12.5% (n=4, mean age 38yrs), never resumed pre transplanted cycles, & 16%@=6) became menopausal within the first year after CTX, at mean age of 47.5 yrs (range 40-52). There were 5 post CTX pregnancies: 2 TAB, & 3 live births. Group 3: 57?@=52) of the females were no longer menstruating @ time of CTX. Of these, 46% (n=24) had undergone hysterectomy prior to CTX & 54 o/0(11=28)selfreported to b=e menopausal prior to CTX. Of the amenorrheic females 39% were on hormone replacement therapy. Repotted gynecologic problems for the sample included: yeast infection (IO%),genital herpes (4.3%), condylomata (3.2%), decreased libido (4.3%), vaginal dryness. Three post menopausaal females reported having had positive pap screening exam.
zymes, Immunoglobulms, complement and anti ptg antibodies. After cardtac arrest ossue samples were taken for histological examinaoon (light/electron microcopy (LMiEM) and immunohistochemistry). Results: IT prolonged the workmg time of hearts. IA had no addltional impact but was effective alone (Table 1). Heart weight mcreased significantly in G2 without IA and IT. CO and CF in G2 was sigmficantly lower compared to the other 3 groups. IA only improved CO in G4 (vs. G3, p
to menache,
(*p
Conclusion: It appears that CTX does not affect menstrual cycles for premenopausal females; in pcrimenopausal females, menopause may occur earlier than the general population.
99 97
REGULATORY ROLES XENOGRAFT REJECTION.
OF
CHEMOKINES
IN
Mulligan MS, Warner RL, Boiling SF, Ward PA, University MI
DELAYED
CARDIAC
Group 1 (IT) 356k46.1 5.67kO.81 193.3f16.1 157.!xz9.15
Group 2 125f31.3 * 23.9kk.24 * 155+86.8* 59.4f20.1*
Group 3 (IT + IA) 310i44.2 8.18*1.59 19s.s+15.4 172.lCll.S
Group 4 (IA) 335zt37.4 5.69k1.43 338.5fl6.0* 151.2klO.9
ANALYSIS OF RISK FACTORS FOR CHRONIC LUNG REJECTION FROM A TWELVE-CENTER,, MULTINATIONAL DATABASE T.R. Brazelton*, R.L. Doyle+, C. Pouter*+, R.L. WongS, R.D. Newmarkt, C. Bush&-J. Altin er*, H. Hausen*, B.A. Reitz*, J. Theodore+, R.E. Morris*, and the International J! ung Transplant Database Grou Surg* & Pulm Med+, Stanford Univ., CA and Novartis Pharm. P , E.T?- anover, NJ cardiothor
of Michigan, Ann Arbor,
The regulatory effects of the beta chemokines MCP-1, RANTES and MIP-la in cardiac allograft survival has recently been described in rats. Currently, the hyperacute rejection of cardiac xenografts has been well described and a requirement for complement in this process has been delineated. Little is known about the mediation of the delayed xenograft rejection which occurs in the presence of complement depletion. We hypothesized that the same beta chemokines which help mediate cardiac allograft rejection may be important in xenograft rejection. Sixty three Heterotopic cardiac transplants was performed from golden cyrean hamster donors to Lewis rat recipients (a concordant xeno mismatch). Three beta chemokines were studied. MCP- 1 an early gene product that attracts monocytes to site of inflammation with little effect on neutrophils or lymphocytes; RANTES from the same supergene family as IL-E, which attracts memory T-cells and monocytes but not neutrophils; MIP-la which is chemotactic for all leukocytes and stimulates macrophage production of TNF, IL-1 and IL-6. One alpha chemokine, KC (analogous to CINC) which is chemotactic for neuuophils was studied for the sake of comparison. Control xenograft recipients received non-immune rabbit serum and daily injections of cobra venom factor for complement depletion to overcome hyperacute rejection. Additional complement depleted recipients were treated with antisera to MCP-I, RANTBS, MIP-la or KC. Hyperacute xenograft rejection resulted in graft loss at 2.5 days in complement-intact animals. Complement depletion delayed graft loss until 7 days following transplantation. While treatment with anti MIP-la and anti KC did not prolong graft survival in complement depleted animals, treatment with anti-MCP-1 or anti-RANTES extended graft so&al to 8.8 and 9.9 days respectively. Additional animals were sacrificed at 2, 4 and 6 days following transplantation and northern blot analysis was performed to correlate regulatory effects with increased mRNA expression. These data suggest a similar pattern of chemokine mediator requirements for cardiac allograft rejection and delayed cardiac xenograft rejection. Those chemokines primarily involved in mononuclear cell recruitment and activation (beta) and not neutrophil recruitment (alpha) appear to play the dominant roles in mediating subacute xenograft rejection.
status versus suspect factors were also excluded as risks for CR includin age of donor(D) 01 recipient(R), antibad induction, cardiac b pass, center, gend! matches (MRJMD, &/MD, MRIFD, &D), hei ht rni&~~~ z&r $?:o”” rimary and secondary reasons for LTx, type. of Ls x. and the ‘year of LT:: i? onclusion: A thorough investigation of a large number of otential risks factors for CR revealed that only >2 acute rejection events, CM 5 infection and an incompatible I m hccyte cross-match were significantly associated with the development o ?I!C ‘Ihts study also provides strong evidence that several previously susoected risk factors includine araft ischemic time and ore-TX CMV seroloev. as wcfi as several novel potential-risk factors, m not significantly associated w&the development of chrome lung rejection. #U.S.A. (Cedars-Sinai, Cleveland Clin, Columbia U., Duke U., Lo ola U., U. of Pitt., Stanford, and UCSF); Australia (Alfred Hos ,, Melbourne and St. Vincent’s Hosp., Sydney); Europe (Hannover Med School anB Papworth Hosp., Cambridge).
100
98
59
HETEROGENEITY AND REVERSAL BRONCHIOLITIS OBLITERANS SYNDROME T.R. Brazelton’, R.L?oyle+ R.L. Wang+ R.D. NewmarkS. C. Bush+, J. llwxlore+, R.E. Morris*, & the’ Intemational’Lun Transplant Database Group#, Depts. Cardiothor. Sur ,* & Pulm. Med.+, Stanfor d Univ.. CA & Novartis PharmaceuticalsS. E. Hanover. RJ
INFLUENCE OF ISCHEMIC TIME ON HYPERACUTE XENOGRAFT REJECTION IN A WORKING PIG HEART MODEL WITH IMMUNOADSORPTION P. Brenner’. M. Him’, H. H&r’, M. Schmoeckel’. H. Reichenspumer’. B. Meiser’, C. Hammer’, B. Rexhart’. ‘Dept.of Cardiac Surgery. ‘Inst. f. Surg.Research, University of Munich (LMU), Germany Purpose: Ischemla and reperfusion inJury after long whemic time (IT) is supposed to have a marked mfluence on hyperacute xenograft rejection (HXR). Xenoreactive, natural anhbodies (XNAb) as a trigger of HXR were ehminated by lmmunoadsorpoon (IA) using a IgThemsorb” column. Aim of our study was to mvestlgate the influence of different (cold ischemlc tunes on HXR of ex viva ,,working pig hearts” perfused with human blood. Methods: Hearts of I2 Landrace pigs (I 3-3 I kg) were explanted after cardioplegla wth CelsiorDsohmon. Hearts of group Gl (n=6) underwent 4 hours of ischemia prior to start of xenoperfusion. Hearts of control group G2 (~6) were kept ischemic for 46.6kl5.8 mmotes. In
group G3 (n=6) wth 4 hours of lT and in group G4 (n=6) wth 5 I .2+4.2 mm of IT wo cycles of IA removed unmunoglobulins IgG, 1gM and IgA from perfusate. In working heart mode hemodynamlc parameters hke blood pressure, ECG, Cardiac Output (CO) and Coronary Flow (CF) were measured. Blood samples were collected to determine myocardlal en-
(CR) was defined as the first CR, BOSl and OB (*SE) at 1 yr was 188f1.5, 10%f1.21 and 104bfl.1, and at 5 yrs was 70%f2.9, 60%f3.2, and 358f2.8. Hazard analysis indicated that OB had aa approximately constant nsk of occurrin from the time of TX through 6 yn post-TX, while the hazard rate for BOSl peaked a$ er the first gra& remained steady until 5 yrs post-Tx. The hazard rates for both BOSl and OB e negligible aftex these time pomts suggesting that ts who are free from CR after 6 rs are at a daxaxd risk of developing CR. The R aplan-Meier (KM) incidences (* HE) for BOS progression are listed table.
in
the There
was cxtensiVe variability the progressio” all groups
KMineidence l%l n
~0~1 t0~o.Q
in ~0~210~0~3 of EKm toe063 as
m!w
l!mamQmuLul
259 o.1715t -8
170 0.1507+ 19i3.0 loo O-2060+ 4-ti.4
-4 6X3.6 64i3.6 3513.5 4433.9 57i4.1 lW.3 2333.0 ?s335
ent3.6 m.6 63H.7
The Journal of Heart and Lung Transplantation January 1999
60 Abstracts
documented b the high standard deviations for BOSI to BOS2(?1303d) and BOSZ to BOS3 (&323d progression. Multivariate analysis revealed that faster progression from BOSl to BOS2 was not associated with risk factors for CR (inch&in acute rejection or CMV infection) nor other potential risk factors including earlier OS1 post-TX. Interestin ly, a shorter time spent in BOSl is a hi hly si nificant rusk factor for a faster B d S2 to BOS3 progression (p=O.o005, &=.924~moonth sp:nt m BOSl). Several ts had sustained im rovements in their FIX1 sufftcient to ratnow them from their B 8 S classification. 0 P the 2.59 ta who ualiiied for BOSI, 10.0% returned to “no BOS” status in a mean time of ! 26 d (S &1811). Similarly, 8.2% of pts with BOS2 returned to BOSl (Mean =243d, SMl63) and 0.0% of pts with BOS3 returned to BOS2 (Mean=316d, SDf87). Conclusion: In covtras! to{mm,y publt!hed re. arts, these data indicates that the progressjon of BOS IS lughl vanab e wth a soi set of patients (-20%) progressin very ra tdly while another so set (-40%) takes from 3-5 yrs to progress from 80 1 1 to B 8 S3. Given this heterogeneity and the si nificant subsets of patients that “tecover” from BOS. our results highlight the difficulty of evaluating treatments for BOS in small clinical trials. #U.S.A. (Cedars-Sinai, Cleveland Clin, Columbia U., Duke U., Lo ola U.! U. of Pitt.. Stanford, and UCSF); Australia (Alfred Hos ., Melbourne and St. Vmcent’s Hosp., Sydney); Europe (Hannover Med School and $ apworth Hosp., Cambridge).
101
94%, 94% and 84% in the control group (p = 0.0003). The patients m the SDL group required significantly longer ICU stays - 10.9 days compared to 4.2 days in the control group (p= 0.0006). Demographic data, FEV, following transplant, and freedom from developing BOS grade hvo or higher were comparable among the groups. Conclusion: Employing lungs from donors who are shorter than the prospective recipient when performing single lung transplant for obstructive lung disease appears to adversely affect hospital course and survwal in a statistically significant manner.
103
CORONARY atOF HUMAN CARDLW ALLOGRATS WITH lllmmum c!oRoNARY ARTmY DISEASE CONIAIN olAswmNAL C.A. SkcW, V. Jwatudam*, B. PORJLATIONS OF T L-. ‘Dept. Micmbiol. & Imaumol., QePt. Sugezy, )Dept. Goktmu?, C.D. Plsbmcd, Pathol.. TampIe Univ. sch. of Mad., Phil&&&, PA. To~~~l~~~ofTcellsuspresmtintbc lymph@ infitirnte in wmwy u(srise of btmua cardiac altogratIs with chmaic ,-e&&n, we seqtad &ebeia TCR traascripts tiwn M aaterior dweadiag (LAD)~in~arasripbtcomvryuteriPs(RCA)from~ogrPflsoffive patiats. We employed tlw noa+admmic adaptor PCR (NPA-PCR), which was pvioudy developed ia our Momtory for the am@icatioa of cDNAs which have varid& or uuknmva 5’ ads, such as TCR and 18. fotlowed by ctonin8 and seqw,&g of the a@ifkd tmwcripts. Cardiac exphw fmm patkats ~~58 obtain ~~~~witha~~~.TotnlRNAwu,isolptedfromthsLADMd RCA aad ds cDNA was syntbesimd. LAD cDNA was ligated to a nowpaliadmmic adrptor, nmplifkd, clotted ad qd. Sequaw analysis fmm one patient me&d atbetant*l poaioas of ideaticat &cbaia TCR transcripts, one of which was V~S.lD~l.lJ~l.1 (18%). The [email protected] clonal expansion was confinned by~iod~tPmptifi~~method(huo-sidedVBS.l-specificPCR), uiagRCA cDNA fmm the same gratl. The TCR transcript initially found to be clonally expauded in Ihe LAD by NPA-PCR wae ako found to be clomdly expanded in RCA wing $95.1~specific PCR. Ia the second patient, 18% of 33 j3-chaia TCR tmnscripta is&ted fmm the LAD were idea&at (Val2.1 D,?l.lJB1.4). All these traascripta wem novoL Slightly lower pm~&iona of identical B-cbaia TCR traawiptswmidmtiSediotbe mmainkg 3 pattats atIer NPA-PCR amplificatioa. However, scqwce analysis of TCR tmascripta using V&specific PCR yielded incmad pmptiwof identical tmnmiFts. Noti gmripheml blood mononuclear ce.us (PBMC) wme usal 8s ooahd ad, a atkipeted for polychd Fophtions of T cells, alI PBMC TCR tranwri@ were unique whea compared to each other. The preaaw of oligocloaal popuiatiwu of T cells in the mjected graft suggest that these cells have undagaba specific aatipaodrivm pmlifemtioa aod clonal expansion at the site of tbs gmft ia rraplnss to aa as-ye&u&nowa atloantigetl. Supported in part by PO1 AI40161 aad T32 AI07101 fmm NM.
104
EPlTHELIAL REGROWTH PREVENTS LUMINAL OCCLUSION IN ORTHOTOPIC TRACHEAL ALLOGRAFTS DESPITE ACUTE FXIECTION AND PROLIFERATION OF a-ACTIN POSITIVE CELLS. T. S. Ikonen, R. S. Shorthouse, G. J. Berry, and R. E. Morris. Stanford University, Stanford, California. In our earlier study we have shown that anastomosis of isograft segments to heterotopic tracheal allografts will induce the growth of isogeneic epithelium into the allograft preventing luminal obliteration. In the present study we wanted to test the impact of epithelial m-growth on the development of OAD in orthotopic tracheal allografis. Methods: Orthotopic tracheal transplants from BN rats were performed on 22 Lewis rats. Donor tracheas were cut to the length of 5 to I rings and anastomosed with 8-O prolene end-to-end into the upper third of the recipient trachea. No immunosuppression was used. The tracheas were harvested at days 3, 7, 10, 30, and 60 for histology (H&E and Masson’s Trichrome). Computerized morpbometry including obliteration (S tissue inside the tracheal ring) and epithelial coverage, and semiquantitative immunohistology with staining of pan-T cell, CD-4, CD-8, ED-l, NK cell, MHC class II, and a-actin antibodies were analyzed. Results: Rats sacrificed between days 3 and 10 had a typical picture of acute alloimmune injury in tracheal grafts with extensive lymphocytic infiltration and initial epithelial damage and m-growth. All day 30 and 60 allografts were 100% coveted by cuboidal or attenuated epitbelium. Immunohistology showed that the presence of immunelogically active cells in the tracheal wall (both inside and outside the cartilage ring) declined between days 30 and 60, though there was stilt a moderate number of positive cells at day 60. The epithelium had numerous T-cells with a high CD4/CD8 ratio. The tracheal wall between the cartilage and the epithelium showed moderate a-actin staining at day 30 and mild to moderate a-actin staining at day 60 as an indicator of onset of OAD in the allograft tracheas. However, the extent of luminal obliteration did not differ between day 7, 30 and 60 allografts (34.78, 30.5%, and 32.5%, respectively), although the obliteration in allografts was significantly higher than in the adjacent host tracheas (19.5%, t5.6%, 19.9%, respectively) or in no-1 tracheas (14.1%). Conelusions: We describe, for the fust time, long-term patency of orthotopic tracheal grafts without any immunosuppression or preservation in a fully incompatible rat strain combination. Despite florid acute altoimmune injury and the Induction of proliferation of a-actin positive cells, epithelial re-growth (presumably from the host trachea) limits the progression of OAD in orthotopic tracheal altogratis, emphasizing the role of epithelium in the control of airway obliteration.
RESULTS OF EXPANDABLE METAL STENT PLACEMENT IN LUNG TRANSPLANT RFCIPIENTS. MA F&z, JG Carirli, MS Gwvm, ED Frisked, JA Alexander, ED Stapka. Dapt of Medicine, Radiology aad SW, University of Florida, Gainesville, Flcrida, USA. INTRODUCTION: Airway complications such as hmnchomakcia and Expa&bk metal bmnchostewis am often eawmwed after lung hansplantation. stents have been used to address this form of ahway complications. We sport on theirincidenwand outcomeaRerexpandabkmetalstentpkcemant METEIOD: our mldy popuktion corlsim of 8s patialts that tltdmvat 91 luttg traspht opmiots (65 SLT and 26 BLT) and sawived more than 30 days. The
iucideuce of symptomatic (dyspa or decline in FEVl) bmnchoswmsis and bmnchomalacia is mpmted. Thebmnchklaa&oomsiswaspcrformedby telescoping the bmnchi and using simple and httermpied 4-O sutuma for the membratmtts bmnchus. All symptomatic patknts with bmachwwwis or bmnchom&cia tmdwveat eqxudable metal stent (Walktent “f placement. The prccedute was done under conscious sedation. The location of the lesion was\ identiried by fibemptic bmachoscopy and dwn the Walk&d N was de@oyed under
fluomswpic
guidance.
Follow-up was done by performing serial bmwhoswpks at The complkatioas atIer stmt placement am repoti. RFSULTB: lo/88 patkats had either symptomatic bmn&nukcia or bmachoslewsis afkr tran@antation mqahing WaUstent’y placement. 5 patkats had WaustentNplacedattherigbtanastomosis,and5~WaIlpent*placcdattheleA anastomcuis. Stentswempkcedanaverageof87dayspcstw@antadon. Three stentsplacedinthe~mainstcmbronchusoverlappsdtheuppcrlobeorifice,and1 overkpptdboththeuppexaadmiddlebbeoritices. OnestentplacedintbektImaia stem bmnchas cverkpped the upper lobe orifice. The mean follow-up after stent placementws19months(mage6-36months). Ncmeofthepatientswithoverkp of their lobar orifices had post obstructive pneumonia. AS patknts reported symptomatic i mpmvement, with an average incmase iu PEVl of 400/e after stezltblg, Three patients had growth of granulation tissue thmngh the stent, causing 25-s% hunid rMenosis. None were symptomatic or mquimd bmnchodilation, CONCLUSION: Symptomatic bmachcsknosis or bmnchomakck occurs in pmvides SymPtomatic relief approximately 10% of tmwphmt mcipknts. wallstent” in Ihe majority of those recipients. Restenosis mte remains high atIer Walktent N placement. However, ove@ping of upper lobe orifices by Walktent w is not associated with post obstmctive pnemnoaia. 3-6 months intewals.
102
DECREASED SURVIVAL ASSOCIATED WITH SIZE MIS-MATCHING IN LUNG TRANSPLANTATION. S.J Park. D. Nguyen, K Savik, J. Dunitz, M. Hertz, R. M. Bolman III. University of Minnesota, Minneapolis, MN, USA Appropriate size match between donor and recipient is consldered to be important in yielding optimal outcome following lung transplantation. Size match based on height is a common practice, but the impact on clinical outcome associated with such practice has been poorly understood. To address this question, a homogenoos group ofpatients was analyzed, those receiving single lung transplantation for obstructive lung disease. Seventy-one consecutive patients were identified OXI the past nine years and entered into the study. Each patient was given a we match number based on donorireclpient height ratio (d/r ratio). the ratios were distributed normally, and the mean was 1.05 2 0.078. Patients whose d/r ratio deviated more or less than one standard deviation from the mean were analyzed to assess the impact of d/r ratio on FEV, following transplant, freedom from developing BOS grade two or higher, ICU stay and survival. Results: Twelve patients received lungs from small donors (d/r ratio more than one standard deviation below the mean). This was designated the small donor lung group (SDL). Similarly 12 patients received lungs from large donors (d/r ratio more than one standard deviation above the mean). This group was designated as the large donor long group (LDL). The remaining 47 patients had a d/r ratio within one standard deviation of the mean. This was the control group. The significant difference ,,, survival was noted between the SDL and control groups. Six-month, one-year and three-Year survival rates were 83%, 73%, and 50% in the SDL group as compared to
Abstracts
Three groups were identified. Group 1: 3%@=2)tmdewent ClX prior mean age at CTX 7 yrs., age at menarche for 1 subject was 12.5 yrs while the second at 16 yrs never started menses. Group 2: 42%@=38)were menstruating prior to ClX. Of these, 58%@=22) resumed pre CTX cycles within the first yr. following CTX, while 16%(n=6) resumed menses 1 yr. after CTX When compared to age-matched controls, statistical differences were not found for cycle lengtha, duration of flow or regularity; 12.5% (n=4, mean age 38yrs), never resumed pre transplanted cycles, & 16%@=6) became menopausal within the first year after CTX, at mean age of 47.5 yrs (range 40-52). There were 5 post CTX pregnancies: 2 TAB, & 3 live births. Group 3: 57?@=52) of the females were no longer menstruating @ time of CTX. Of these, 46% (n=24) had undergone hysterectomy prior to CTX & 54 o/0(11=28)selfreported to b=e menopausal prior to CTX. Of the amenorrheic females 39% were on hormone replacement therapy. Repotted gynecologic problems for the sample included: yeast infection (IO%),genital herpes (4.3%), condylomata (3.2%), decreased libido (4.3%), vaginal dryness. Three post menopausaal females reported having had positive pap screening exam.
zymes, Immunoglobulms, complement and anti ptg antibodies. After cardtac arrest ossue samples were taken for histological examinaoon (light/electron microcopy (LMiEM) and immunohistochemistry). Results: IT prolonged the workmg time of hearts. IA had no addltional impact but was effective alone (Table 1). Heart weight mcreased significantly in G2 without IA and IT. CO and CF in G2 was sigmficantly lower compared to the other 3 groups. IA only improved CO in G4 (vs. G3, p
to menache,
(*p
Conclusion: It appears that CTX does not affect menstrual cycles for premenopausal females; in pcrimenopausal females, menopause may occur earlier than the general population.
99 97
REGULATORY ROLES XENOGRAFT REJECTION.
OF
CHEMOKINES
IN
Mulligan MS, Warner RL, Boiling SF, Ward PA, University MI
DELAYED
CARDIAC
Group 1 (IT) 356k46.1 5.67kO.81 193.3f16.1 157.!xz9.15
Group 2 125f31.3 * 23.9kk.24 * 155+86.8* 59.4f20.1*
Group 3 (IT + IA) 310i44.2 8.18*1.59 19s.s+15.4 172.lCll.S
Group 4 (IA) 335zt37.4 5.69k1.43 338.5fl6.0* 151.2klO.9
ANALYSIS OF RISK FACTORS FOR CHRONIC LUNG REJECTION FROM A TWELVE-CENTER,, MULTINATIONAL DATABASE T.R. Brazelton*, R.L. Doyle+, C. Pouter*+, R.L. WongS, R.D. Newmarkt, C. Bush&-J. Altin er*, H. Hausen*, B.A. Reitz*, J. Theodore+, R.E. Morris*, and the International J! ung Transplant Database Grou Surg* & Pulm Med+, Stanford Univ., CA and Novartis Pharm. P , E.T?- anover, NJ cardiothor
of Michigan, Ann Arbor,
The regulatory effects of the beta chemokines MCP-1, RANTES and MIP-la in cardiac allograft survival has recently been described in rats. Currently, the hyperacute rejection of cardiac xenografts has been well described and a requirement for complement in this process has been delineated. Little is known about the mediation of the delayed xenograft rejection which occurs in the presence of complement depletion. We hypothesized that the same beta chemokines which help mediate cardiac allograft rejection may be important in xenograft rejection. Sixty three Heterotopic cardiac transplants was performed from golden cyrean hamster donors to Lewis rat recipients (a concordant xeno mismatch). Three beta chemokines were studied. MCP- 1 an early gene product that attracts monocytes to site of inflammation with little effect on neutrophils or lymphocytes; RANTES from the same supergene family as IL-E, which attracts memory T-cells and monocytes but not neutrophils; MIP-la which is chemotactic for all leukocytes and stimulates macrophage production of TNF, IL-1 and IL-6. One alpha chemokine, KC (analogous to CINC) which is chemotactic for neuuophils was studied for the sake of comparison. Control xenograft recipients received non-immune rabbit serum and daily injections of cobra venom factor for complement depletion to overcome hyperacute rejection. Additional complement depleted recipients were treated with antisera to MCP-I, RANTBS, MIP-la or KC. Hyperacute xenograft rejection resulted in graft loss at 2.5 days in complement-intact animals. Complement depletion delayed graft loss until 7 days following transplantation. While treatment with anti MIP-la and anti KC did not prolong graft survival in complement depleted animals, treatment with anti-MCP-1 or anti-RANTES extended graft so&al to 8.8 and 9.9 days respectively. Additional animals were sacrificed at 2, 4 and 6 days following transplantation and northern blot analysis was performed to correlate regulatory effects with increased mRNA expression. These data suggest a similar pattern of chemokine mediator requirements for cardiac allograft rejection and delayed cardiac xenograft rejection. Those chemokines primarily involved in mononuclear cell recruitment and activation (beta) and not neutrophil recruitment (alpha) appear to play the dominant roles in mediating subacute xenograft rejection.
status versus suspect factors were also excluded as risks for CR includin age of donor(D) 01 recipient(R), antibad induction, cardiac b pass, center, gend! matches (MRJMD, &/MD, MRIFD, &D), hei ht rni&~~~ z&r $?:o”” rimary and secondary reasons for LTx, type. of Ls x. and the ‘year of LT:: i? onclusion: A thorough investigation of a large number of otential risks factors for CR revealed that only >2 acute rejection events, CM 5 infection and an incompatible I m hccyte cross-match were significantly associated with the development o ?I!C ‘Ihts study also provides strong evidence that several previously susoected risk factors includine araft ischemic time and ore-TX CMV seroloev. as wcfi as several novel potential-risk factors, m not significantly associated w&the development of chrome lung rejection. #U.S.A. (Cedars-Sinai, Cleveland Clin, Columbia U., Duke U., Lo ola U., U. of Pitt., Stanford, and UCSF); Australia (Alfred Hos ,, Melbourne and St. Vincent’s Hosp., Sydney); Europe (Hannover Med School anB Papworth Hosp., Cambridge).
100
98
59
HETEROGENEITY AND REVERSAL BRONCHIOLITIS OBLITERANS SYNDROME T.R. Brazelton’, R.L?oyle+ R.L. Wang+ R.D. NewmarkS. C. Bush+, J. llwxlore+, R.E. Morris*, & the’ Intemational’Lun Transplant Database Group#, Depts. Cardiothor. Sur ,* & Pulm. Med.+, Stanfor d Univ.. CA & Novartis PharmaceuticalsS. E. Hanover. RJ
INFLUENCE OF ISCHEMIC TIME ON HYPERACUTE XENOGRAFT REJECTION IN A WORKING PIG HEART MODEL WITH IMMUNOADSORPTION P. Brenner’. M. Him’, H. H&r’, M. Schmoeckel’. H. Reichenspumer’. B. Meiser’, C. Hammer’, B. Rexhart’. ‘Dept.of Cardiac Surgery. ‘Inst. f. Surg.Research, University of Munich (LMU), Germany Purpose: Ischemla and reperfusion inJury after long whemic time (IT) is supposed to have a marked mfluence on hyperacute xenograft rejection (HXR). Xenoreactive, natural anhbodies (XNAb) as a trigger of HXR were ehminated by lmmunoadsorpoon (IA) using a IgThemsorb” column. Aim of our study was to mvestlgate the influence of different (cold ischemlc tunes on HXR of ex viva ,,working pig hearts” perfused with human blood. Methods: Hearts of I2 Landrace pigs (I 3-3 I kg) were explanted after cardioplegla wth CelsiorDsohmon. Hearts of group Gl (n=6) underwent 4 hours of ischemia prior to start of xenoperfusion. Hearts of control group G2 (~6) were kept ischemic for 46.6kl5.8 mmotes. In
group G3 (n=6) wth 4 hours of lT and in group G4 (n=6) wth 5 I .2+4.2 mm of IT wo cycles of IA removed unmunoglobulins IgG, 1gM and IgA from perfusate. In working heart mode hemodynamlc parameters hke blood pressure, ECG, Cardiac Output (CO) and Coronary Flow (CF) were measured. Blood samples were collected to determine myocardlal en-
(CR) was defined as the first CR, BOSl and OB (*SE) at 1 yr was 188f1.5, 10%f1.21 and 104bfl.1, and at 5 yrs was 70%f2.9, 60%f3.2, and 358f2.8. Hazard analysis indicated that OB had aa approximately constant nsk of occurrin from the time of TX through 6 yn post-TX, while the hazard rate for BOSl peaked a$ er the first gra& remained steady until 5 yrs post-Tx. The hazard rates for both BOSl and OB e negligible aftex these time pomts suggesting that ts who are free from CR after 6 rs are at a daxaxd risk of developing CR. The R aplan-Meier (KM) incidences (* HE) for BOS progression are listed table.
in
the There
was cxtensiVe variability the progressio” all groups
KMineidence l%l n
~0~1 t0~o.Q
in ~0~210~0~3 of EKm toe063 as
m!w
l!mamQmuLul
259 o.1715t -8
170 0.1507+ 19i3.0 loo O-2060+ 4-ti.4
-4 6X3.6 64i3.6 3513.5 4433.9 57i4.1 lW.3 2333.0 ?s335
ent3.6 m.6 63H.7
The Journal of Heart and Lung Transplantation January 1999
60 Abstracts
documented b the high standard deviations for BOSI to BOS2(?1303d) and BOSZ to BOS3 (&323d progression. Multivariate analysis revealed that faster progression from BOSl to BOS2 was not associated with risk factors for CR (inch&in acute rejection or CMV infection) nor other potential risk factors including earlier OS1 post-TX. Interestin ly, a shorter time spent in BOSl is a hi hly si nificant rusk factor for a faster B d S2 to BOS3 progression (p=O.o005, &=.924~moonth sp:nt m BOSl). Several ts had sustained im rovements in their FIX1 sufftcient to ratnow them from their B 8 S classification. 0 P the 2.59 ta who ualiiied for BOSI, 10.0% returned to “no BOS” status in a mean time of ! 26 d (S &1811). Similarly, 8.2% of pts with BOS2 returned to BOSl (Mean =243d, SMl63) and 0.0% of pts with BOS3 returned to BOS2 (Mean=316d, SDf87). Conclusion: In covtras! to{mm,y publt!hed re. arts, these data indicates that the progressjon of BOS IS lughl vanab e wth a soi set of patients (-20%) progressin very ra tdly while another so set (-40%) takes from 3-5 yrs to progress from 80 1 1 to B 8 S3. Given this heterogeneity and the si nificant subsets of patients that “tecover” from BOS. our results highlight the difficulty of evaluating treatments for BOS in small clinical trials. #U.S.A. (Cedars-Sinai, Cleveland Clin, Columbia U., Duke U., Lo ola U.! U. of Pitt.. Stanford, and UCSF); Australia (Alfred Hos ., Melbourne and St. Vmcent’s Hosp., Sydney); Europe (Hannover Med School and $ apworth Hosp., Cambridge).
101
94%, 94% and 84% in the control group (p = 0.0003). The patients m the SDL group required significantly longer ICU stays - 10.9 days compared to 4.2 days in the control group (p= 0.0006). Demographic data, FEV, following transplant, and freedom from developing BOS grade hvo or higher were comparable among the groups. Conclusion: Employing lungs from donors who are shorter than the prospective recipient when performing single lung transplant for obstructive lung disease appears to adversely affect hospital course and survwal in a statistically significant manner.
103
CORONARY atOF HUMAN CARDLW ALLOGRATS WITH lllmmum c!oRoNARY ARTmY DISEASE CONIAIN olAswmNAL C.A. SkcW, V. Jwatudam*, B. PORJLATIONS OF T L-. ‘Dept. Micmbiol. & Imaumol., QePt. Sugezy, )Dept. Goktmu?, C.D. Plsbmcd, Pathol.. TampIe Univ. sch. of Mad., Phil&&&, PA. To~~~l~~~ofTcellsuspresmtintbc lymph@ infitirnte in wmwy u(srise of btmua cardiac altogratIs with chmaic ,-e&&n, we seqtad &ebeia TCR traascripts tiwn M aaterior dweadiag (LAD)~in~arasripbtcomvryuteriPs(RCA)from~ogrPflsoffive patiats. We employed tlw noa+admmic adaptor PCR (NPA-PCR), which was pvioudy developed ia our Momtory for the am@icatioa of cDNAs which have varid& or uuknmva 5’ ads, such as TCR and 18. fotlowed by ctonin8 and seqw,&g of the a@ifkd tmwcripts. Cardiac exphw fmm patkats ~~58 obtain ~~~~witha~~~.TotnlRNAwu,isolptedfromthsLADMd RCA aad ds cDNA was syntbesimd. LAD cDNA was ligated to a nowpaliadmmic adrptor, nmplifkd, clotted ad qd. Sequaw analysis fmm one patient me&d atbetant*l poaioas of ideaticat &cbaia TCR transcripts, one of which was V~S.lD~l.lJ~l.1 (18%). The [email protected] clonal expansion was confinned by~iod~tPmptifi~~method(huo-sidedVBS.l-specificPCR), uiagRCA cDNA fmm the same gratl. The TCR transcript initially found to be clonally expauded in Ihe LAD by NPA-PCR wae ako found to be clomdly expanded in RCA wing $95.1~specific PCR. Ia the second patient, 18% of 33 j3-chaia TCR tmnscripta is&ted fmm the LAD were idea&at (Val2.1 D,?l.lJB1.4). All these traascripta wem novoL Slightly lower pm~&iona of identical B-cbaia TCR traawiptswmidmtiSediotbe mmainkg 3 pattats atIer NPA-PCR amplificatioa. However, scqwce analysis of TCR tmascripta using V&specific PCR yielded incmad pmptiwof identical tmnmiFts. Noti gmripheml blood mononuclear ce.us (PBMC) wme usal 8s ooahd ad, a atkipeted for polychd Fophtions of T cells, alI PBMC TCR tranwri@ were unique whea compared to each other. The preaaw of oligocloaal popuiatiwu of T cells in the mjected graft suggest that these cells have undagaba specific aatipaodrivm pmlifemtioa aod clonal expansion at the site of tbs gmft ia rraplnss to aa as-ye&u&nowa atloantigetl. Supported in part by PO1 AI40161 aad T32 AI07101 fmm NM.
104
EPlTHELIAL REGROWTH PREVENTS LUMINAL OCCLUSION IN ORTHOTOPIC TRACHEAL ALLOGRAFTS DESPITE ACUTE FXIECTION AND PROLIFERATION OF a-ACTIN POSITIVE CELLS. T. S. Ikonen, R. S. Shorthouse, G. J. Berry, and R. E. Morris. Stanford University, Stanford, California. In our earlier study we have shown that anastomosis of isograft segments to heterotopic tracheal allografts will induce the growth of isogeneic epithelium into the allograft preventing luminal obliteration. In the present study we wanted to test the impact of epithelial m-growth on the development of OAD in orthotopic tracheal allografis. Methods: Orthotopic tracheal transplants from BN rats were performed on 22 Lewis rats. Donor tracheas were cut to the length of 5 to I rings and anastomosed with 8-O prolene end-to-end into the upper third of the recipient trachea. No immunosuppression was used. The tracheas were harvested at days 3, 7, 10, 30, and 60 for histology (H&E and Masson’s Trichrome). Computerized morpbometry including obliteration (S tissue inside the tracheal ring) and epithelial coverage, and semiquantitative immunohistology with staining of pan-T cell, CD-4, CD-8, ED-l, NK cell, MHC class II, and a-actin antibodies were analyzed. Results: Rats sacrificed between days 3 and 10 had a typical picture of acute alloimmune injury in tracheal grafts with extensive lymphocytic infiltration and initial epithelial damage and m-growth. All day 30 and 60 allografts were 100% coveted by cuboidal or attenuated epitbelium. Immunohistology showed that the presence of immunelogically active cells in the tracheal wall (both inside and outside the cartilage ring) declined between days 30 and 60, though there was stilt a moderate number of positive cells at day 60. The epithelium had numerous T-cells with a high CD4/CD8 ratio. The tracheal wall between the cartilage and the epithelium showed moderate a-actin staining at day 30 and mild to moderate a-actin staining at day 60 as an indicator of onset of OAD in the allograft tracheas. However, the extent of luminal obliteration did not differ between day 7, 30 and 60 allografts (34.78, 30.5%, and 32.5%, respectively), although the obliteration in allografts was significantly higher than in the adjacent host tracheas (19.5%, t5.6%, 19.9%, respectively) or in no-1 tracheas (14.1%). Conelusions: We describe, for the fust time, long-term patency of orthotopic tracheal grafts without any immunosuppression or preservation in a fully incompatible rat strain combination. Despite florid acute altoimmune injury and the Induction of proliferation of a-actin positive cells, epithelial re-growth (presumably from the host trachea) limits the progression of OAD in orthotopic tracheal altogratis, emphasizing the role of epithelium in the control of airway obliteration.
RESULTS OF EXPANDABLE METAL STENT PLACEMENT IN LUNG TRANSPLANT RFCIPIENTS. MA F&z, JG Carirli, MS Gwvm, ED Frisked, JA Alexander, ED Stapka. Dapt of Medicine, Radiology aad SW, University of Florida, Gainesville, Flcrida, USA. INTRODUCTION: Airway complications such as hmnchomakcia and Expa&bk metal bmnchostewis am often eawmwed after lung hansplantation. stents have been used to address this form of ahway complications. We sport on theirincidenwand outcomeaRerexpandabkmetalstentpkcemant METEIOD: our mldy popuktion corlsim of 8s patialts that tltdmvat 91 luttg traspht opmiots (65 SLT and 26 BLT) and sawived more than 30 days. The
iucideuce of symptomatic (dyspa or decline in FEVl) bmnchoswmsis and bmnchomalacia is mpmted. Thebmnchklaa&oomsiswaspcrformedby telescoping the bmnchi and using simple and httermpied 4-O sutuma for the membratmtts bmnchus. All symptomatic patknts with bmachwwwis or bmnchom&cia tmdwveat eqxudable metal stent (Walktent “f placement. The prccedute was done under conscious sedation. The location of the lesion was\ identiried by fibemptic bmachoscopy and dwn the Walk&d N was de@oyed under
fluomswpic
guidance.
Follow-up was done by performing serial bmwhoswpks at The complkatioas atIer stmt placement am repoti. RFSULTB: lo/88 patkats had either symptomatic bmn&nukcia or bmachoslewsis afkr tran@antation mqahing WaUstent’y placement. 5 patkats had WaustentNplacedattherigbtanastomosis,and5~WaIlpent*placcdattheleA anastomcuis. Stentswempkcedanaverageof87dayspcstw@antadon. Three stentsplacedinthe~mainstcmbronchusoverlappsdtheuppcrlobeorifice,and1 overkpptdboththeuppexaadmiddlebbeoritices. OnestentplacedintbektImaia stem bmnchas cverkpped the upper lobe orifice. The mean follow-up after stent placementws19months(mage6-36months). Ncmeofthepatientswithoverkp of their lobar orifices had post obstructive pneumonia. AS patknts reported symptomatic i mpmvement, with an average incmase iu PEVl of 400/e after stezltblg, Three patients had growth of granulation tissue thmngh the stent, causing 25-s% hunid rMenosis. None were symptomatic or mquimd bmnchodilation, CONCLUSION: Symptomatic bmachcsknosis or bmnchomakck occurs in pmvides SymPtomatic relief approximately 10% of tmwphmt mcipknts. wallstent” in Ihe majority of those recipients. Restenosis mte remains high atIer Walktent N placement. However, ove@ping of upper lobe orifices by Walktent w is not associated with post obstmctive pnemnoaia. 3-6 months intewals.
102
DECREASED SURVIVAL ASSOCIATED WITH SIZE MIS-MATCHING IN LUNG TRANSPLANTATION. S.J Park. D. Nguyen, K Savik, J. Dunitz, M. Hertz, R. M. Bolman III. University of Minnesota, Minneapolis, MN, USA Appropriate size match between donor and recipient is consldered to be important in yielding optimal outcome following lung transplantation. Size match based on height is a common practice, but the impact on clinical outcome associated with such practice has been poorly understood. To address this question, a homogenoos group ofpatients was analyzed, those receiving single lung transplantation for obstructive lung disease. Seventy-one consecutive patients were identified OXI the past nine years and entered into the study. Each patient was given a we match number based on donorireclpient height ratio (d/r ratio). the ratios were distributed normally, and the mean was 1.05 2 0.078. Patients whose d/r ratio deviated more or less than one standard deviation from the mean were analyzed to assess the impact of d/r ratio on FEV, following transplant, freedom from developing BOS grade two or higher, ICU stay and survival. Results: Twelve patients received lungs from small donors (d/r ratio more than one standard deviation below the mean). This was designated the small donor lung group (SDL). Similarly 12 patients received lungs from large donors (d/r ratio more than one standard deviation above the mean). This group was designated as the large donor long group (LDL). The remaining 47 patients had a d/r ratio within one standard deviation of the mean. This was the control group. The significant difference ,,, survival was noted between the SDL and control groups. Six-month, one-year and three-Year survival rates were 83%, 73%, and 50% in the SDL group as compared to