title: A comparative analysis of bronchial stricture after lung transplantation in recipients with and without early acute rejection.
abstract: BACKGROUND
  Risk factors and outcomes of bronchial stricture after lung transplantation are not well defined. An association between acute rejection and development of stricture has been suggested in small case series. We evaluated this relationship using a large national registry.
  
  
  METHODS
  All lung transplantations between April 1994 and December 2008 per the United Network for Organ Sharing (UNOS) database were analyzed. Generalized linear models were used to determine the association between early rejection and development of stricture after adjusting for potential confounders. The association of stricture with postoperative lung function and overall survival was also evaluated.
  
  
  RESULTS
  Nine thousand three hundred thirty-five patients were included for analysis. The incidence of stricture was 11.5% (1,077/9,335), with no significant change in incidence during the study period (P=0.13). Early rejection was associated with a significantly greater incidence of stricture (adjusted odds ratio [AOR], 1.40; 95% confidence interval [CI], 1.22-1.61; p<0.0001). Male sex, restrictive lung disease, and pretransplantation requirement for hospitalization were also associated with stricture. Those who experienced stricture had a lower postoperative peak percent predicted forced expiratory volume at 1 second (FEV1) (median 74% versus 86% for bilateral transplants only; p<0.0001), shorter unadjusted survival (median 6.09 versus 6.82 years; p<0.001) and increased risk of death after adjusting for potential confounders (adjusted hazard ratio 1.13; 95% CI, 1.03-1.23; p=0.007).
  
  
  CONCLUSIONS
  Early rejection is associated with an increased incidence of stricture. Recipients with stricture demonstrate worse postoperative lung function and survival. Prospective studies may be warranted to further assess causality and the potential for coordinated rejection and stricture surveillance strategies to improve postoperative outcomes.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA. anthony.castleberry@duke.edu
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Castleberry
authors.forename: Mathias
authors.initials: M
authors.lastname: Worni
authors.forename: Maragatha
authors.initials: M
authors.lastname: Kuchibhatla
authors.forename: Shu S
authors.initials: SS
authors.lastname: Lin
authors.forename: Laurie D
authors.initials: LD
authors.lastname: Snyder
authors.forename: Scott L
authors.initials: SL
authors.lastname: Shofer
authors.forename: Scott M
authors.initials: SM
authors.lastname: Palmer
authors.forename: Ricardo
authors.initials: R
authors.lastname: Pietrobon
authors.forename: R Duane
authors.initials: RD
authors.lastname: Davis
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Hartwig
mesh_terms: D000208:Acute Disease; D000328:Adult; D000367:Age Factors; D001982:Bronchial Diseases / Q000209:etiology* / Q000401:mortality* / Q000503:physiopathology; D015331:Cohort Studies; D003251:Constriction, Pathologic / Q000453:epidemiology* / Q000209:etiology / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D016040:Lung Transplantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: 12; 95% CI; 95% confidence interval; AOR; BMI; FEV(1); IQR; OPTN; Organ Procurement and Transplantation Network; Po(2); UNOS; United Network for Organ Sharing; adjusted odds ratio; arterial partial pressure of oxygen; body mass index; forced expiratory volume at 1 second (as a percent of the patient's predicted value); interquartile range