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Table 1 Summary of role of additional common tests in the workup of graft dysfunction

From: Imaging indications and findings in evaluation of lung transplant graft dysfunction and rejection

WorkupUses
BronchoscopyBAL: to exclude infection. Infection is considered in the differential of PGD, acute rejection (ACR, AMR), and BO/BOS.
TBB:
 ACR: histopathological findings are the gold standard diagnostic test.
 AMR: histopathological findings and positive C4d stain are suggestive diagnostic features.
 BO: pathological findings are characteristic; disease is patchy and biopsy may be negative; not required for diagnosis.
 Recurrence of the primary lung disease such as sarcoidosis.
 Malignancy such as post-transplant lymphoproliferative disorder.
Airway:
 Dehiscence in early post-operative period.
 Stenosis and malacia can cause abnormal spirometry; differential diagnosis of BOS.
SpirometrySensitive in detecting graft dysfunction;
BOS: irreversible obstructive pattern; > > 20% decline in FEV1 of baseline
RAS: irreversible restrictive pattern; > 20% decline in FEV1 of baseline.
EchocardiographyCardiac dysfunction: cardiogenic edema or volume overload may cause diffuse lung opacities and should be considered in the differential of PGD in particular.
CTAPulmonary embolism
Pulmonary venous thrombosis: in the differential diagnosis of PGD.
GERD WorkupAspiration: in the differential of PGD and acute rejection; may co-exist with either one; it is a potential risk factor of BO/BOS
  1. BAL, bronchoalveolar lavage; PGD, primary graft dysfunction; ACR, acute cellular rejection; AMR, antibody-mediated rejection; BOS, bronchiolitis obliterans syndrome; TBB, transbronchial biopsy; FEV1, forced expiratory volume in 1 s; RAS restrictive allograft syndrome