131 The Role of Open Lung Biopsy in Lung-Transplant Recipients: Does the Establishment of Restrictive Allograft Syndrome (RAS) Change Practice?

Abstract

Purpose: Open lung biopsy (Bx) can cause significant morbidity. Restrictive allograft syndrome (RAS) is a novel form of chronic lung allograft dysfunction with characteristic interstitial inflammation and fibrosis. The purpose of the study is to review indications and outcomes of open Bx in the light of the clinical diagnosis of RAS. Methods and Materials: Patients who received bilateral lung or heart lung transplantation (Tx) from 1996 to 2010 were reviewed focusing on indications, complications, and outcomes of open lung Bx. Results: Among 560 patients, 33 underwent open Bx. 14 Bx were indicated secondary to early post-Tx complications (n 13) and esophageal cancer resection (n 1). Open Bx was primarily indicated for nodular lesions (n 4), early inexplicable graft dysfunction after Tx (n 2), and late graft dysfunction (respiratory exacerbation or failure inexplicable by rejection, infection, or typical BOS; n 13). All the nodular lesions reached diagnosis (2 PTLD, 1 abscess, 1 organized infarction) without complications. In contrast, all the Bx indicated for graft dysfunction revealed diffuse alveolar damage (DAD) without infection or rejection that explains the condition. As such, the Bx finding did not change patient management. Prolonged airleak or chest tube placement 2 weeks was common among those who had late graft dysfunction (8/13 cases). Increased oxygen requirement or prolonged mechanical ventilation was documented in 5 cases. Applying the diagnostic criteria for RAS (decline in both FEV1 80% and total lung capacity (TLC) 90% of baselines), 10/13 cases with late graft dysfunction were attributed to RAS; the other 3 showed radiographic characteristics of RAS although patients’ conditions limited access to TLC measurement to confirm the diagnosis. Conclusions: Open Bx was not useful in cases of respiratory failure clinically associated with RAS and was associated with high incidence of complications. Clinical diagnosis of RAS is likely to reduce open Bx in lung transplant recipients with graft dysfunction.