Chronic lung allograft dysfunction after lung transplantation - prevention, diagnosis and treatment in 44 European centers

Background: There is limited data on optimal management of chronic lung allograft dysfunction (CLAD). We aimed to describe the variability of diagnostic and therapeutic practices in Europe.
Methods: A structured questionnaire was sent to 71 centers in 24 countries. Questions were related to contemporary clinical practices for work-up, monitoring and treatment of CLAD. Number of lung transplant (LTx) procedures, patients in follow-up were collected.
Results: Forty-four centers (62%) responded from 20 countries, representing 74% of European activity. The prevalence of CLAD was estimated at 9.1 cases per million population (25th and 75th percentiles 4.4-15.7). Preferred initial work-up for probable CLAD consisted of chest CT (inspiratory 91%, expiratory 74%), donor-specific antibody (DSA) measurement (86%), bronchoalveolar lavage (BAL) (85%), and transbronchial biopsy (81%). For monitoring of definite CLAD, inspiratory CT (67%), DSA (61%), and BAL (43%) were preferred. Body plethysmography was unavailable for 16% of cases. Prophylaxis was based on preventing infections (CMV 99%, inhaled antibiotics 70% and antifungals 65%), tacrolimus-based immunosuppression (96%), azithromycin (72%), and universal proton pump inhibitor treatment (84%). First-line treatment of CLAD was based on azithromycin (82%) and steroid augmentation (74%). Photopheresis was used in 26% of cases.
Conclusion: Current European practice CLAD detection is based on spirometry, inspiratory CT and DSA, with limited access to plethysmography and expiratory CT. Prophylactic treatment is based on azithromycin, tacrolimus-based immunosuppression, and treatment of risk factors. No single treatment strategy is universally used, highlighting the need for an effective treatment of CLAD. The preferred first-line strategy is azithromycin and steroid augmentation.