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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




BAL: to exclude infection. Infection is considered in the differential of PGD, acute rejection (ACR, AMR), and BO/BOS.


 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.


 Dehiscence in early post-operative period.

 Stenosis and malacia can cause abnormal spirometry; differential diagnosis of BOS.


Sensitive in detecting graft dysfunction;

BOS: irreversible obstructive pattern; > > 20% decline in FEV1 of baseline

RAS: irreversible restrictive pattern; > 20% decline in FEV1 of baseline.


Cardiac dysfunction: cardiogenic edema or volume overload may cause diffuse lung opacities and should be considered in the differential of PGD in particular.


Pulmonary embolism

Pulmonary venous thrombosis: in the differential diagnosis of PGD.

GERD Workup

Aspiration: 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