primary graft dysfunction PGD differential diagnosis

PGD is a diagnosis of exclusion and other conditions in the differential diagnosis include volume overload with pulmonary edema, the rare occurrence of hyperacute rejection, infection, antibody mediated rejection, myocardial dysfunction, pneumonia, pulmonary thromboembolism, venous anastomotic stenosis, and transfusion-related acute lung injury (TRALI) that can be evaluated with a transesophageal echocardiogram.

Pulmonary edema could be in the differential diagnosis, but the normal pulmonary artery occlusion pressure and low BNP level suggest against this.

Both hyperacute (rarely) and acute cellular rejection (ACR) are described in lung transplant recipients. Hyperacute rejection is mediated by preformed antibodies to graft antigens such as human leukocyte antigens, and the well-matched direct crossmatch in this case suggests against this. ACR is characterized by shortness of breath, sometimes a perihilar opacity or effusion, and typically would develop later than this (choice C is incorrect). It is a diagnosis made with transbronchial biopsy showing perivascular lymphocytic infiltrates. Treatment is with corticosteroids with good response.

CMV pneumonitis, for which this patient is at risk given the mismatch status, does not develop this early and is less likely to develop with ganciclovir prophylaxis (choice B is incorrect).

Stenosis at a pulmonary venous anastomosis does manifest with a pulmonary edema picture at radiography and would be unusual to be bilateral. In addition, the transesophageal echocardiography performed at the end of the case in the operating room is helpful to exclude this diagnosis (choice D is incorrect).

TRALI could also be in the differential diagnosis, but the last blood products were many hours before this presentation, so it is less likely. Other infections such as bacterial pneumonia would be unusual this early after lung transplant.1234567

Footnotes

  1. SEEK Questionnaires ↩

  2. Cantu E, Diamond JM, Cevasco M, et al. Contemporary trends in PGD incidence, outcomes, and therapies. J Heart Lung Transplant. 2022;41(12):1839-1849. PubMed ↩

  3. Diamond JM, Arcasoy S, Kennedy CC, et al. Report of the International Society for Heart and Lung Transplantation Working Group on Primary Lung Graft Dysfunction, part II: epidemiology, risk factors, and outcomes-a 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2017;36(10):1104-1113. PubMed ↩

  4. Harano T, Ryan JP, Morrell MR, et al. Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation. ASAIO J. 2021;67(9):1071-1078. PubMed ↩

  5. Natalini JG, Clausen ES. Critical care management of the lung transplant recipient. Clin Chest Med. 2023;44(1):105-119. PubMed ↩

  6. Natalini JG, Diamond JM. Primary graft dysfunction. Semin Respir Crit Care Med. 2021;42(3):368-379. PubMed ↩

  7. Snell GI, Yusen RD, Weill D, et al. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part I: definition and grading-a 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2017;36(10):1097-1103. PubMed ↩