Elsevier

Transplantation Proceedings

Volume 53, Issue 1, January–February 2021, Pages 296-302
Transplantation Proceedings

Advances in Transplantation
Lung Transplantation
Outcomes Following Extracorporeal Photopheresis for Chronic Lung Allograft Dysfunction Following Lung Transplantation: A Single-Center Experience

https://doi.org/10.1016/j.transproceed.2020.09.003Get rights and content

Highlights

  • Extracorporeal photopheresis can slow decline in lung function from chronic lung allograft dysfunction.

  • Not all patients with chronic lung allograft dysfunction respond to extracorporeal photopheresis.

  • Female sex, low neutrophil count, and prior treatment with anti-thymocyte globulin appear to limit response to extracorporeal photopheresis.

Abstract

Introduction

Survival following lung transplantation (LTx) is limited by the development of chronic lung allograft dysfunction (CLAD), for which there are few effective therapies and no standardized management. Several small studies have demonstrated the effectiveness of extracorporeal photopheresis (ECP) as a therapeutic option for CLAD.

Methods

A retrospective descriptive audit of 12 LTx recipients who received rescue ECP for CLAD over 5 years (2013-2018) at the Alfred Hospital, Melbourne, Australia, was completed. Nonresponders to ECP were defined as patients who experienced a 20% decrease in forced expiratory volume (FEV1) within 6 weeks of commencing therapy.

Results

Mean time since LTx was 849 days and mean time since diagnosis of CLAD was 131 days. Fifty-eight percent of patients were male (n = 7) and 67% responded to ECP therapy (n = 8). Among responders, the mean (95% confidence interval) decline in FEV1 pre-ECP was 9.0 mL/day (5-12 mL/day), compared to 1.4 mL/day (0-4 mL/day) post-ECP (P = .01). Among nonresponders, mean (95% confidence interval) decline in FEV1 was 7.2 mL/day (4-10 mL/day) pre-ECP and 5.0 mL/day (3-7 mL/day) post ECP (P = .2). Nonresponders were more likely to be female (P = .01) and neutropenic (P = .005). Patients with prior exposure to anti-thymocyte globulin had a lowered response to ECP.

Conclusion

Rescue ECP arrested the decline of lung function in 67% of patients with CLAD. Sex, pre-ECP neutrophil count, and exposure to anti-thymocyte globulin may help determine response to ECP. Future clinical trials are needed to confirm this effect, help predict response to therapy, and ultimately guide the placement of ECP in the treatment algorithm for CLAD.

Section snippets

Methods

We performed a retrospective descriptive audit of all LTx patients who underwent ECP treatment from 2013 until June 2018.

Demographics

Twelve patients underwent ECP as rescue therapy for CLAD from November 2013 to June 2018. Patient demographics are described in Table 1. Baseline immunosuppression and previous therapies for CLAD are described in Table 2. All patients achieved therapeutic levels of immunosuppression as per our hospital protocol. All patients, except 1, were taking azithromycin at time of ECP commencement (drug intolerance, nausea).

Seventeen percent had rejection evident on transbronchial biopsy International

Discussion and Conclusion

Despite being introduced as late rescue therapy, there did appear to be an efficacy signal, with 67% of CLAD patients demonstrating a reduction in the rate of declining FEV1 from 9.0 to 1.4 mL/day. Morrell et al reported a similar single-center experience of patients receiving ECP for BOS and found a mean difference in rate of decline of 87.1 mL/month [15]. Pecoraro et al reported a single-center experience of 54 patients with BOS, 15 of whom received ECP therapy. Patients who received ECP had

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