CLAD monitoring and management practices across North American lung transplantation centers

Results from a Cystic Fibrosis-Lung Transplant Consortium (CFLTC) study, characterizing chronic lung allograft dysfunction (CLAD) monitoring and management practices across 21 North American lung transplantation centers, were published in the Journal of Heart and Lung Transplantation by Kapnadak et al. A 35-question REDCap survey was distributed to centers and addressed immunosuppression regimens, monitoring and testing for graft function and CLAD risk factors, and centers’ approach to lung function decline that persisted after management of acute clinical entities. 

Key data: All 21 centers utilized tacrolimus + mycophenolate mofetil + prednisone for routine immunosuppression. Prophylactic azithromycin was routinely used by 33.3% of centers. In terms of utility, 38.1% of centers reported a belief that azithromycin prevents loss of lung function and 57.1% were uncertain of its effectiveness. Gastroesophageal reflux (GER) testing was performed for all patients before and after lung transplantation in 33.3% of centers. Of 19 centers that responded to questions on proton pump inhibitor (PPI) use, 63.2% routinely prescribed PPIs to all recipients. A persistent forced expiratory volume in 1 second (FEV₁) decline ≥10% was considered clinically meaningful by 71.4% of centers. However, intervention strategies varied, with intravenous corticosteroids and additional immunosuppression agents considered by 66.7% and 61.9% of centers, respectively, for a 10–20% FEV₁ decline, and extracorporeal photopheresis (ECP) and additional immunosuppression agents considered by 81.0% and 66.7% of centers, respectively, for a >20% decline. 

Key learning: In this study, heterogeneity was observed across North American adult lung transplantation centers in azithromycin practices, GER testing and management, and FEV₁ intervention thresholds, highlighting critical knowledge gaps and the need for prospective studies to inform evidence-based CLAD prevention and management.