Recurrence of Sarcoidosis in Pulmonary Allograft Recipients

Abstract

Lung transplantation is a potentially curative therapy for the end-stage pulmonary sequelae of sarcoidosis. We reviewed the course of five lung allograft recipients with underlying sarcoidosis (S) at the University of Pittsburgh Medical Center and compared them with a control group (C) of 44 contemporaneous transplant recipients with other respiratory diseases. Sarcoid granulomata have developed in the allografts of 4 S, although these lesions have not yet been demonstrated to result in clinically significant abnormalities. In comparison with C, sarcoidosis patients had significantly greater mean grades of acute rejection during the first 3 months after transplantation (2.1 +/- 0.3 versus 1.6 +/- 0.1, S and C, respectively, p < 0.042) and larger proportions of lung biopsies showing more than mild acute rejection (40 versus 18%, p < 0.012) and lymphocytic bronchitis (30 versus 13%, p = 0.02), as well as a greater percentage of polymorphonuclear leukocytes in BAL returns (34.9 +/- 5.4 versus 19.0 +/- 1.6, p < 0.01). The two groups did not differ, however, in frequency of obliterative bronchiolitis, survival, or pulmonary function. We conclude that lung transplant recipients with underlying sarcoidosis are very likely to develop recurrent disease in the allograft and have more severe acute rejection responses, especially in the first weeks after transplantation. Pulmonary transplantation appears to be an efficacious therapy for end-stage sarcoidosis, but the long-term sequelae of the increased acute rejection and recurrent sarcoidosis in the allograft remain to be determined.

Lung Transplantation for Pulmonary Sarcoidosis

“…Other research shows that Sarcoidosis patients, when compared to other lung transplant recipients, have a predilection for severe, acute rejection. Acute rejection is a recognised risk factor for the development of BOS or chronic rejection suggesting Sarcoidosis patients might have a worse long term outcome after transplant (Johnson, Duncan et al 1993). On review the evidence for an increased incidence of BOS in Sarcoidosis patients is lacking and suggests that the numbers involved in this study are too small to draw definitive conclusions on long term outcomes while others have shown equivocal outcomes to other transplant diagnosis (Padilla, Schilero et al 1997;Wille, Gaggar et al 2008;Keating, Levvey et al 2009).…”

“…To date around 21 cases are recorded with two further reports of recurrence in an undocumented number (Collins, Hartman et al 2001). The estimated frequency is calculated as 50% but the range between reported series has been between 25 and www.intechopen.com 80% (Johnson, Duncan et al 1993;Bjortuft, Foerster et al 1994;Walker, Mikhail et al 1998;Burke, Stewart et al 2001;Milman, Burton et al 2005). Although rates are varied Black Americans seem to have a higher recurrence rate at 66% compared to other races (Nunley, Hattler et al 1999).…”

“…Sarcoidosis, however, is not the only disease that recurs following lung transplant and a list of the other reported conditions is in Table 2. In the majority of cases, recurrence of Sarcoidosis is not preceded by an increase in respiratory symptoms and signs (Johnson, Duncan et al 1993;Nunley, Hattler et al 1999). Usually cases of recurrence are identified as part of surveillance bronchoscopies carried out routinely post procedure.…”

“…In some cases however there may be evidence of graft dysfunction with the onset of respiratory symptoms, and in these patients there is a greater likelihood that there are coexisting infiltrates on radiological investigations (Judson 1998). Recurrence can occur at any stage post transplantation documented from as early as 2 weeks out to 2 years (Johnson, Duncan et al 1993;Martel, Carre et al 1996). Some have suggested that rejection and Sarcoidosis may utilise a common pathway via the activation of Tlymphocytes however, the weight of evidence is against this.…”

Recurrent sarcoid granulomas in a transplanted lung derive from recipient immune cells: Fig. 1—

“…Recurrence appears to be higher, ,66%, in African-American patients [10]. Other series have reported recurrence rates of between 33-80% [11][12][13].…”