OBLITERATIVE BRONCHIOLITIS The most frequent cause of death after the second posttransplant year is obliterative bronchiolitis (OB), characterized by chronic allograft dysfunction and airflow limitation. Current evidence suggests that chronic rejection plays the most important role in the development of OB, but other factors such as CMV infection, toxic fume inhalation, and chronic foreign-body exposure caused by abnormal mucociliary clearance may contribute as well. Diagnostically, the yield from bronchoscopy and biopsy is low. Therefore, diagnosis rests on clinical criteria (i.e., > 20 percent fall in FEV : without any other identifiable cause). Since the large airways become bronchiectatic as the small airways are obliterated, episodes of bacterial bronchitis are common. Typically the chest radiograph is clear of infiltrates. Current treatment is augmentation of immunosuppression and high-dose steroids. The prevalence of OB syndrome in long-term survivors is 20 to 50 percent. The course of the disease is highly variable, with some patients stabilizing at a lower level of pulmonary function and others progressing to respiratory failure and death.
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