Joan G. Clark

Obstructive Lung Disease after Allogeneic Marrow Transplantation: Clinical Presentation and Course

To describe the clinical presentation and progression of obstructive lung disease after marrow transplantation, we examined a sequential sample of 35 patients who had allogeneic marrow transplantation between January 1980 and January 1987, were 16 years or older, had normal pulmonary function tests before transplantation, and developed airflow obstruction defined as FEV1/FVC less than 70% and FEV1 less than 80% predicted 50 days or more after transplantation. Cases were selected from 1029 adult (older than 16 years) patients who underwent allogeneic marrow transplantation during the same period. Patients with airflow obstruction presented with symptoms of cough, dyspnea, or wheezing, or a combination. In 80% the chest radiograph was normal. Airflow obstruction was diagnosed within 1.5 years after transplantation in 33 of 35 patients. Clinical, extensive, chronic graft-versus-host disease was present in 24 patients. Only 4 patients had a complete response to primary therapy of chronic graft-versus-host disease. Serum IgG and IgA levels were decreased in 15 and 25 patients, respectively. The FEV1 declined rapidly (decrease in FEV1 greater than 30% between tests) in 21 patients, but 14 patients with slowly progressive or reversible disease were identified. Mortality was 65% at 3 years after transplant, a significantly higher value (P = 0.016) than the 3-year mortality rate of 44% in a comparison group of 412 concurrent patients with chronic graft-versus-host disease who were 16 years or older, survived more than 80 days after transplantation, and had normal pulmonary function. We concluded that obstructive lung disease after marrow transplantation may be variable with respect to time of onset and rate of progression. Obstructive lung disease was frequently associated with serum immunoglobulin deficiency and clinical, extensive, chronic graft-versus-host disease that was not readily responsive to treatment. Mortality was high but long-term survivors were identified.

Type III Procollagen Peptide in the Adult Respiratory Distress Syndrome: Association of Increased Peptide Levels in Bronchoalveolar Lavage Fluid with Increased Risk for Death

The adult respiratory distress syndrome frequently results in a fibroproliferative response and excessive lung extracellular matrix accumulation that may preclude recovery [1, 2]. An analysis of lung tissue from patients who died of the adult respiratory distress syndrome provided biochemical evidence that collagen, the major extracellular matrix component of lung, was greatly increased [3]. Immunohistologic evaluation of lung tissue from patients with the adult respiratory distress syndrome showed an abundance of type I and type III collagen, with type III collagen predominating earlier in the disease course [4]. Collagen accumulation in the adult respiratory distress syndrome results, at least in part, from increased procollagen synthesis, a mechanism that has been shown in numerous animal models of acute lung injury [5, 6]. Further, excessive lung collagen synthesis and accumulation may contribute to the high fatality rates associated with the adult respiratory distress syndrome by promoting progressive respiratory dysfunction. Alternatively, excessive lung collagen synthesis might indirectly influence outcome by impeding resolution of respiratory failure and increasing the risk for subsequent fatal complications, including multiple organ dysfunction. The relation between collagen synthesis and clinical outcomes in the adult respiratory distress syndrome has been difficult to examine directly. However, the N-terminal peptide of type III procollagen (procollagen III), cleaved from the precursor procollagen molecule during synthesis, appears to be a useful marker of collagen synthesis. Increased levels of procollagen III have been detected in serum from patients with sarcoidosis [7], idiopathic pulmonary fibrosis [8-10], and the adult respiratory distress syndrome [11, 12], as well as other conditions involving tissue fibrosis, such as cirrhosis [13], wound healing [14], trauma [12], and myelofibrosis [15]. In patients with idiopathic pulmonary fibrosis, increased procollagen III concentrations in bronchoalveolar lavage fluid were strongly associated with indices of clinical disease severity [10]. Although increased levels of procollagen III have been detected in lavage fluid from a few patients with the adult respiratory distress syndrome [16], their association with clinical outcome has not been examined. We analyzed procollagen III levels from bronchoalveolar lavage fluid in patients with the adult respiratory distress syndrome and studied the relation of increased lavage procollagen III levels to fatality rates. Methods Patients All patients between the ages of 18 and 72 years who were admitted to intensive care units at Harborview Medical Center [Seattle, Washington] between September 1986 and April 1991 were screened prospectively for the onset of the adult respiratory distress syndrome. Patients were screened using the following criteria: 1) for critical hypoxemia with cutoff Pao 2/Fio 2 ratios of 150 mm Hg or less or of 200 mm Hg or less using 5 cm H2O or more of positive end-expiratory pressure; 2) for diffuse parenchymal infiltrates involving at least three quadrants on chest radiographs; 3) for pulmonary artery wedge pressure [when available] of 18 mm Hg or less or no clinical evidence of congestive heart failure; and 4) no other obvious explanation for these findings [17, 18]. Because of the possible risk for complications related to bronchoalveolar lavage, patients with the adult respiratory distress syndrome were excluded if they met any of the following criteria: 1) Pao 2 less than 80 mm Hg with Fio 2 of 1.0; 2) evidence of acute ischemic heart disease; 3) severe hypotension (systolic blood pressure < 90 mm Hg); 4) cardiac dysrhythmias (heart rate > 140 beats/min or complex ventricular ectopy); 5) sustained increased intracranial pressure greater than 20 mm Hg; and 6) endotracheal tube internal diameter less than 7.0 mm. Patients were not excluded because of high minute ventilation, high levels of positive end-expiratory pressure, or presence of barotrauma. Informed consent was obtained from either the patient or the legal surrogate. The study was approved by the University of Washington Human Review Committee. Before bronchoalveolar lavage was done, the following clinical data were obtained: levels of Fio 2 and Pao 2, static compliance, and level of positive end-expiratory pressure. These data were used to calculate a modified lung injury score for the adult respiratory distress syndrome, as described by Murray and colleagues [19], except that a chest radiograph score was not included. However, all patients had alveolar infiltrates in three or four quadrants. Thus, the Murray acute lung injury score would be 0.75 to 1.0 points greater than our modified score. Patients in our study with lung injury scores of 1.75 or more met Murray criteria for severe lung injury. Risk factors associated with development of the adult respiratory distress syndrome were defined as previously described [17]. These included the sepsis syndrome, trauma, aspiration of gastric contents, drug overdose, and multiple transfusions. Trauma risk was defined as the presence of multiple long bone or pelvic fractures, pulmonary contusion, or trauma-associated multiple transfusions ( 15 units in 24 hours of emergency resuscitation) [17]. For this analysis, we combined clinical risks for aspiration of gastric contents, drug overdose, and multiple transfusions without trauma into the category other risks. Risk factors were identified prospectively when the patient was entered into the study. The first 18 patients in the study had a single bronchoalveolar lavage. Subsequently, we attempted to do lavage serially at days 3, 7, and 14 after the onset of the adult respiratory distress syndrome unless the patient died, was extubated, or became too unstable to tolerate a lavage, as indicated by the criteria above. Patients were followed until death or hospital discharge. Survival was defined as discharge from hospital. Organ failure and cause of death, as defined by Montgomery and colleagues [18], were analyzed in a subset of patients enrolled during 1990. Bronchoalveolar Lavage and Analyses All patients were intubated at the time of lavage. They were ventilated with Fio 2 levels of 1.0 for 10 to 15 minutes before and during the procedure. An adaptor was placed on the patients endotracheal tube, and a fiberoptic bronchoscope was passed through the endotracheal tube into the lower airway and was wedged into a subsegment of either the right middle lobe or lingula. Five 30-mL aliquots of sterile pyrogen-free 0.9% NaCl at room temperature were instilled (150 mL total) and recovered by gentle suction. Six normal volunteers had lavage using a similar technique. Serum samples also were obtained from patients at the time of lavage and were stored at 70C. Lavage samples were transported immediately to the laboratory for analysis. The fluid was filtered through gauze moistened with 0.9% NaCl, and the total recovered volume was recorded. Total cell counts were done in a hemacytometer, and differential cell counts were done on cytospin preparations stained with Diff-Quick (American Scientific Products, McGaw Park, Illinois). Cell viability was measured by trypan blue exclusion. After an aliquot was taken for cellular analysis, the lavage fluid was centrifuged at 200 g for 15 minutes to pellet the cells. Aliquots of the supernatant lavage fluid were put into polypropylene tubes and stored at 70C. Total protein was measured on an aliquot of the supernatant using either the modified Lowry method [20] or the bicinchoninic acid method [21]. Type III Procollagen Peptide Analysis The concentration of procollagen III in bronchoalveolar lavage fluid specimens or serum was determined by radioimmunoassay (RIAgnost PAP, Behringwerke, Marburg, Germany) according to the manufacturers instructions using 20 L of lavage fluid or serum. The radioimmunoassay for procollagen III was linear over a range of 0.4 to 9.5 U/mL. Serum control samples provided by the manufacturer contained 1.6 to 1.7 U/mL. Samples in which the procollagen III concentration was greater than the standard detection range were diluted 1:4 in 0.9% NaCl. Samples in which procollagen III concentrations were less than the detection range were assigned a value of 0.4 U/mL for subsequent data analysis. To determine the variability of repeat determinations, five lavage samples were analyzed in triplicate. The variability of triplicate determinations of procollagen III concentration measured in five different lavage samples was 5% or less. In one analysis, an aliquot of the lavage sample was subjected to a total of three freeze-thaw cycles to determine stability of the peptide under these conditions. No increase in the variability of measured values was detected. Cross-sectional and Serial Analyses Lavage fluid procollagen III concentrations in survivors and nonsurvivors initially were compared using the nonparametric Wilcoxon rank-sum test [22]. We then calculated the relative risk (RR) for fatality in patients with a lavage fluid procollagen III level of 1.75 U/mL or more compared with those with values less than 1.75 U/mL; 95% CIs were determined using the method of Rothman [23]. We also did a stratified analysis to determine if the relation between procollagen III concentration and fatality differed by risk factor for the adult respiratory distress syndrome (sepsis, trauma, other) or degree of lung injury, using the lung injury score. The difference in RRs for death among risk groups for the adult respiratory distress syndrome and lung injury severity groups was assessed by the Breslow-Day test of homogeneity [24]. We did logistic regression analyses of data obtained on days 3, 7, and 14 after onset of the adult respiratory distress syndrome to measure the effect of procollagen III levels on the risk for death while controlling for the effect of demographic and physiologic variables that, independ

Risk Factors for Airflow Obstruction in Recipients of Bone Marrow Transplants

Obstructive lung disease is a complication of bone marrow transplantation. To identify risk factors we analyzed pulmonary function tests of 281 adult patients 1 year after marrow transplantation. The forced expiratory volume at 1 second divided by the forced vital capacity (FEV1/FVC) was used to measure airflow rates. Factors associated with a lower year-1 FEV1/FVC (%) included increased age (p less than 0.0001), male gender (p = 0.02), cigarette smoking (p = 0.01), lower FEV1/FVC before transplantation (p less than 0.0001), HLA-nonidentical grafts (p = 0.001), chronic graft-versus-host disease (p = 0.0002), and immunosuppressive therapy with methotrexate (p = 0.01). There was no significant association between the year-1 FEV1/FVC and underlying disease, dose of conditioning irradiation, or development of acute graft-versus-host disease. Linear multivariate regression analysis, after controlling for the FEV1/FVC before transplantation, shows both chronic graft-versus-host disease and administration of methotrexate independently associated with decrements in the year-1 FEV1/FVC. The combined occurrence of chronic graft-versus-host disease and methotrexate also was strongly associated with decreases in the year-1 FEV1/FVC, indicating an interaction of these risk factors.

Rapid Detection of Cytomegalovirus Pulmonary Infection by Bronchoalveolar Lavage and Centrifugation Culture

Cytomegalovirus infection remains a major cause of morbidity and mortality in marrow transplant recipients. Results of a rapid centrifugation viral culture of bronchoalveolar lavage specimens from 33 marrow transplant recipients with pneumonia were compared with those for conventional viral culture of concurrently or subsequently obtained lung tissue. The centrifugation culture results were also compared to results of cytologic and immunochemical examination of these specimens. Centrifugation culture was positive within 16 hours of inoculation in 22 of 23 (96%) specimens from patients with positive conventional culture of lung tissue. Detection of cells positive for cytomegalovirus by immunofluorescent antibody staining or cytologic identification was less sensitive (59% and 29%, respectively). There was no evidence of cytomegalovirus in specimens from patients without evidence of cytomegalovirus pulmonary infection by any technique. The sensitivity (96%) and specificity (100%) of centrifugation culture of specimens from marrow transplant recipients approach that of viral culture of lung tissue.

Pulmonary venoocclusive disease following bone marrow transplantation.

We report two cases of pulmonary venoocclusive disease (PVOD) in children with acute lymphoblastic leukemia treated by marrow allograft transplantation following conditioning with high-dose 1-3 bis chloroethyl-1 nitrosourea (BCNU), etoposide (VP-16), and cyclophosphamide (Cy). Both patients developed symptomatic pulmonary hypertension documented by right heart catheterization. Open-lung biopsy of one patient demonstrated PVOD evident even on frozen sections stained with hematoxylin and eosin. High-dose methylprednisolone was associated with significant clinical improvement in both patients. Pulmonary symptoms resolved in one patient who subsequently died in leukemic relapse. PVOD resolved in the other patient, only to recur when steroids were discontinued and then again respond to reinstitution of therapy. More aggressive therapy for malignant diseases may increase the incidence of PVOD. Prompt recognition of its subtle clinical and histological manifestations allows early institution of steroid therapy, which may be beneficial.

Idiopathic pneumonia after bone marrow transplantation: cytokine activation and lipopolysaccharide amplification in the bronchoalveolar compartment.

OBJECTIVE To determine whether idiopathic pneumonia syndrome (IPS), a form of noninfectious lung injury that follows bone marrow transplantation, is associated with cytokine activation and increased susceptibility to lipopolysaccharide (LPS). DESIGN Case series. SETTING Tertiary referral center for marrow transplantation. PATIENTS Recipients with biopsy-confirmed IPS; normal volunteers and marrow transplant recipients without IPS were analyzed as controls. MEASUREMENTS AND MAIN RESULTS Levels of lymphocyte and macrophage-derived cytokines as well as components of the LPS, LPS-binding protein (LBP), and CD14 system in bronchoalveolar lavage (BAL) fluid were determined. We found evidence of increased vascular permeability (BAL protein) and inflammatory cytokine activation (interleukin-1, interleukin-2, interleukin-6, and tumor necrosis factor-alpha) in patients with IPS. Patients without IPS had BAL fluid cytokine and protein levels that were similar to levels in BAL fluid from normal volunteers. Moreover, components of the LPS amplification system (LBP and soluble CD14) were increased in patients with IPS but not in patients without IPS. CONCLUSIONS These results provide direct evidence for proinflammatory cytokine activation in IPS and suggest that these patients might be at increased risk for LPS-mediated injury through the LBP amplification pathway.

Immunolocalization of Transforming Growth Factor-α, Epidermal Growth Factor (EGF), and EGF-Receptor in Normal and Injured Developing Human Lung

ABSTRACT: The family of growth factors that includes epidermal growth factor (EGF) and transforming growth factor-α (TGF-α) are thought to play a role in the regulation of fetal lung development and epithelial repair after injury. To further elucidate the potential role of these growth factors and their receptor in normal human lung development and in response to injury, their distribution was determined by immunohistochemistry in normal fetal lung, as well as both normal and injured postnatal human lung. We studied 14 specimens of human lung tissue: from three fetuses, four normal infants, two preterm infants with hyaline membrane disease, and five infants with late bronchopulmonary dysplasia (BPD). EGF, TGF-α, and EGF receptor (EGF-R) colocalized in airway epithelium in normal fetal and in postnatal human lung. They were also colocalized in scattered alveolar epithelial cells in postnatal lung. Large numbers of alveolar macrophages immunostained for EGF, TGF-α, and EGF-R in lungs with late stages of BPD. The colocalization of these growth factors suggests parallel expression of EGF family members. Moreover, the colocalization of these growth factors with their receptor in developing lung suggests that they may act through an autocrine mechanism. The prominent expression of these growth factors in alveolar macrophages in BPD suggests they may be involved with the pathogenesis of this disease.

Incidence, risk factors, and mortality from pneumonia developing late after hematopoietic stem cell transplantation

Summary:The incidence, etiology, outcome, and risk factors for developing pneumonia late after hematopoietic stem cell transplantation (SCT) were investigated in 1359 patients transplanted in Seattle. A total of 341 patients (25% of the cohort) developed at least one pneumonic episode. No microbial or tissue diagnosis (ie clinical pneumonia) was established in 197 patients (58% of first pneumonia cases). Among the remaining 144 patients, established etiologies included 33 viral (10%), 31 bacterial (9%), 25 idiopathic pneumonia syndrome (IPS, 7%), 20 multiple organisms (6%), 19 fungal (6%), and 16 Pneumocystis carinii pneumonia (PCP) (5%). The overall cumulative incidence of first pneumonia at 4 years after discharge home was 31%. The cumulative incidences of pneumonia according to donor type at 1 and 4 years after discharge home were 13 and 18% (autologous/syngeneic), 22 and 34% (HLA-matched related), and 26 and 39% (mismatched related/unrelated), respectively. Multivariate analysis of factors associated with development of late pneumonia after allografting were increasing patient age (RR 0.5 for <20 years, 1.2 for >40 years, P=0.009), donor HLA-mismatch (RR 1.6 for unrelated/mismatched related, P=0.01), and chronic graft-versus-host disease (GVHD; RR 1.5, P=0.007). Our data suggest that extension of PCP prophylaxis may be beneficial in high-risk autograft recipients. Further study of long-term anti-infective prophylaxis based on patient risk factors after SCT appear warranted.

Implications of early airflow decline after myeloablative allogeneic stem cell transplantation

Summary:The clinical significance of early airflow decline after myeloablative allogeneic hematopoietic SCT is uncertain. We performed a retrospective cohort analysis to determine if airflow decline by day 100 is associated with later development of transplant-related airflow obstruction (AFO) and increased mortality risk. Overall, 750 (40%) patients had airflow decline by day 100. Development of airflow decline by day 100 was associated with an increased risk for AFO at 1 year (relative risk 2.6, 95% confidence interval 2.1–3.1) but not with an increase in mortality risk (hazard ratio (HR) 0.86, P=0.05). However, patients with the fastest rate of decline between day 100 and 1 year (12.5% per year ±24) had the highest mortality risk (HR 3.2, P<0.001). In conclusion, airflow measurements made on day 100 do not predict the rate of airflow decline between day 100 and 1 year, and therefore are not useful as a single measurement for determining mortality risk associated with development of AFO. Closer monitoring of the rate of airflow decline during the first year may facilitate the timely detection and treatment of early airflow decline and prevent the development of fixed AFO and increased mortality risk after hematopoietic stem cell transplant.

Pulmonary function testing prior to hematopoietic stem cell transplantation

Summary:The pretransplant pulmonary function test plays an important role in the management of noninfectious pulmonary complications after hematopoietic stem cell transplantation (HCT). Although these tests are widely used as standard preoperative assessments in the nontransplant population, common conditions associated with the HCT patient requires that particular attention be given to interpretation of pulmonary function testing (PFT) results, such as comparison of serial pulmonary function tests and evaluation of the diffusion capacity. Although their utility in helping to predict the likelihood of developing post transplant pulmonary complications and mortality is not well established, current data indicate that pretransplant PFTs are important as a reference for the interpretation of post transplant PFTs and for identifying patients at high risk for developing pulmonary complications and/or mortality after HCT. Future studies of pretransplant pulmonary function should consider the advances in HCT, so that pretransplant PFTs will become a useful tool in pretransplant risk assessment and help the transplant oncologist to determine the most appropriate conditioning regimen for a patient with compromised lung function.