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EUROPEAN RESPIRATORY REVIEW, 2008;17: 93-95. doi:10.1183/09059180.00010813
© 2008 the European Respiratory Society
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The Leuven experience with a dichotomy in Bronchiolitis Obliterans Syndrome (BOS) after lung transplantation revealed by azithromycin

Bart Vanaudenaerde*, Robin Vos*, Nele Geudens#, Dirk Van Raemdonck#, Lieven Dupont* and Geert Verleden*

* Laboratory of Pneumology, KULeuven, Leuven, Belgium, # Laboratory of Experimental Thoracic Surgery, KULeuven, Leuven, Belgium

CORRESPONDENCE: Bart Vanaudenaerde, Laboratory of Pneumology and Lung Transplant Unit, Leuven, Belgium

BOS is the most important cause of late mortality after LTx. Until 5 years ago, the prevalence was around 30% and 50%, 3 and 5 years after LTx. Introduction of azithromycin (AZI) improved the FEV1 in 40% of BOS patients. AZI treatment may explain why in our center, the BOS prevalence at 3 years has decreased from 30% to 15% compared to the ISHLT registry. Opposed to the current belief about BOS, we hypothesize a dichotomy within BOS: Neutrophilic Reversible Allograft Dysfunction (NRAD) and fibropoliferative BOS (fBOS; table 1). This dichotomy is based on the discrepancy in AZI response and observations within our center consisting of clinical, biochemical and cellular (BAL) analysis.


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  		Table 1— A hyphothesised dichotomy

 
NRAD makes a re-evaluation of the BOS definition (irreversible FEV1 decline, neutrophilic inflammation, fibroproliferation) indispensable. As it is reversible, NRAD should be excluded from BOS and accepted as innate (non-specific) inflammation and as an important risk factor for the development of BOS. So after exclusion of other complications such as acute rejection, infection, gastro-oesophageal reflux and after a trial with AZI, BOS will remain what it is now (the fBOS). This implements a re-evaluation of the neutrophilic inflammation, as it is a prerequisite for AZI responsiveness. BOS can then histologically be characterized as pure inactive OB, which is hardly responsive to any treatment.






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