Acute and Chronic Acute and Chronic Rejection Rejection Jessie S. Wilt, MD Jessie S. Wilt, MD Assistant Professor of Clinical Medicine Assistant Professor of Clinical Medicine Associate Medical Director Associate Medical Director - - Lung Transplantation Lung Transplantation Columbia University Columbia University
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Acute and Chronic Acute and Chronic RejectionRejection
Jessie S. Wilt, MDJessie S. Wilt, MDAssistant Professor of Clinical MedicineAssistant Professor of Clinical Medicine
Associate Medical DirectorAssociate Medical Director--Lung TransplantationLung TransplantationColumbia UniversityColumbia University
The RThe R---------------- WordWord
Know the difference between acute and Know the difference between acute and chronic rejectionchronic rejectionUnderstand how each is diagnosedUnderstand how each is diagnosedUnderstand treatment optionsUnderstand treatment options
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Interval % Survival 1 Month 85% 6 Month 67% 1 Year 61% UNOS 1Year 79 % 3 Year 42% UNOS 3 Year 62%
Interval % Survival 1 Month 98% 6 Month 94% 1 Year 93% UNOS 1Year 79 % 3 Year 78% UNOS 3 Year 62%
UNOS 1YR
UNOS 3YR
UNOS 1YR
UNOS 3YR
CPMC
CPMC
ColumbiaColumbia--Presbyterian Medical CenterPresbyterian Medical Center ColumbiaColumbia--Presbyterian Medical CenterPresbyterian Medical CenterKaplanKaplan--Meier Meier -- Patient Patient SurvivalSurvival EstimatesEstimates KaplanKaplan--Meier Meier -- Patient Patient SurvivalSurvival EstimatesEstimatesLung Transplantation Lung Transplantation –– 7/01/1997 to 6/30/2001 Lung Transplantation 7/01/1997 to 6/30/2001 Lung Transplantation –– 7/01/2001 to 12/08/20057/01/2001 to 12/08/2005(n = 92)(n = 92) (n = 136)(n = 136)
PrePre--Program RestructureProgram Restructure Post Program Restructure Post Program Restructure
ADULT LUNG TRANSPLANT RECIPIENTS: Cause Of ADULT LUNG TRANSPLANT RECIPIENTS: Cause Of
DeathDeath (Deaths: January 1992(Deaths: January 1992-- June 2004)June 2004)
CAUSE OF DEATHCAUSE OF DEATH00--30 Days 30 Days (N = 1146)(N = 1146)
PERCENTAGE OF ADULT LUNG TRANSPLANT PERCENTAGE OF ADULT LUNG TRANSPLANT RECIPIENTS TREATED FOR REJECTION IN 1ST YEARRECIPIENTS TREATED FOR REJECTION IN 1ST YEARStratified by Type of Induction (Transplants: January 1, 2000 Stratified by Type of Induction (Transplants: January 1, 2000 -- June 30, 2003)June 30, 2003)
NUMBER OF REJECTION EPISODES FOR ADULT LUNG NUMBER OF REJECTION EPISODES FOR ADULT LUNG TRANSPLANT RECIPIENTS TREATED FOR REJECTION IN TRANSPLANT RECIPIENTS TREATED FOR REJECTION IN 1ST YEAR1ST YEARStratified by Type of Induction (Transplants: January 1, 2000 Stratified by Type of Induction (Transplants: January 1, 2000 -- June 30, 2003)June 30, 2003)
at at low magnificationlow magnificationA3A3 Infiltrates extend into septaeInfiltrates extend into septaeA4A4 Diffuse infiltrates and alveolar Diffuse infiltrates and alveolar
damagedamage-- With/Without Grade BWith/Without Grade B
POSTPOST--LUNG TRANSPLANT MORBIDITY FOR LUNG TRANSPLANT MORBIDITY FOR ADULTSADULTSCumulative Prevalence in Cumulative Prevalence in SurvivorsSurvivors within 1 and 5 Years within 1 and 5 Years PostPost--Transplant Transplant (Follow(Follow--ups: April 1994 ups: April 1994 -- June 2004)June 2004)
Narrowing of the small airwaysNarrowing of the small airwaysLittle inflammatory infiltrateLittle inflammatory infiltrateIrreversibleIrreversibleProgressive airflow obstructionProgressive airflow obstruction
normal
narrowed
Diagnosis of OBDiagnosis of OB
Diagnosis of EXCLUSIONDiagnosis of EXCLUSION–– Exclude infectionsExclude infections–– Exclude airway abnormalitiesExclude airway abnormalities–– Exclude acute rejectionExclude acute rejection
Reduction in Reduction in PFTsPFTs from the from the BESTBEST postpost--transplant baselinetransplant baseline
PFTsPFTs postpost--transplanttransplant
What should your lung function be?What should your lung function be?–– AgeAge–– GenderGender–– HeightHeight–– Donor?Donor?
When are the When are the PFTsPFTs ““the BESTthe BEST””..
Once all other diagnoses are excludedOnce all other diagnoses are excludedMany names:Many names:–– BOS, Chronic rejection, Graft failureBOS, Chronic rejection, Graft failure
Clinical DiagnosisClinical Diagnosis–– TransbronchialTransbronchial biopsy cannot detect the biopsy cannot detect the