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Bone Marrow Transplantation (2001) 27, 1147–1151
 2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00
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Post-transplant complications
Respiratory ciliary function in bone marrow recipients
WY Au, JC Ho, AK Lie, J Sun, L Zheng, R Liang, WK Lam and KW Tsang
University Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
Summary:
Bone marrow transplantation (BMT) recipients, particularly those with chronic graft-versus-host disease
(GVHD), suffer from respiratory tract problems,
including bronchiolitis obliterans (BO) and recurrent
lower respiratory tract infections. Minute cilia beat continuously on the surface of respiratory mucosa, and this
beating maintains the sterility of the lower respiratory
tract. Dysfunction of respiratory cilia could lead to
development of recurrent respiratory tract infections,
which are also features of BMT recipients, although ciliary function has not been systematically studied among
these subjects. We have, therefore, investigated the ciliary beat frequency (CBF) of 36 Chinese patients who
had undergone allogeneic BMT. The CBF was significantly lower in the BMT group compared to controls
(P ⬍ 0.001). The reduction in CBF was more severe in
patients with cGVHD and BO compared with their
counterparts (P = 0.048 and P = 0.077, respectively).
There was a correlation between CBF with forced
expiratory flow rate FEF (P = 0.024) and forced expiratory volume FEV (P = 0.044). We conclude that abnormal ciliary clearance is a common feature after allogeneic BMT, particularly among patients with BO and
cGVHD. Further studies are indicated to evaluate this
important phenomenon, which could be an important
cause of the susceptibility for BMT recipients to respiratory infections. Bone Marrow Transplantation (2001) 27,
1147–1151.
Keywords: bone marrow transplantation; ciliary function; bronchiolitis obliterans; graft-versus-host disease
in the absence of proven infection. The exact mechanism
for the cause of such abnormalities after BMT is unknown,
but there is a documented association with chronic graftversus-host disease (cGVHD), total body irradiation, and
prior chemotherapy exposure.2,3
Cilia are minute hair-like structures present on the surface of respiratory mucosa. Each of these cilia beat continuously at 10–18 Hz, and this beating creates a constant flow
of periciliary fluid, which is responsible for maintaining the
sterility of the lower respiratory tract. Ciliary structure and
function are highly conserved among all species and at different levels of the respiratory tract.4 Dysfunction of respiratory cilia leads to development of recurrent upper and
lower respiratory tract infections, bronchiectasis and small
airway obstruction. This is exemplified by Kartagener’s
syndrome (sinusitis, bronchiectasis and dextrocardia) which
is the most obvious clinical expression of a spectrum of
diseases caused by abnormal ciliary function.5
Defects in ciliary clearance are associated with small airway obstructive diseases and recurrent chest infections.6
The role of ciliary dysfunction in post-BMT bronchiolitis
obliterans (BO) is unknown and there has only been one
report of nasal ciliary assessment in post-BMT patients
with sinusitis. In this study, a high incidence of ultrastructural abnormalities was found, although data on ciliary
beat frequency (CBF) were not presented.7 We have, therefore, performed a cross-sectional evaluation of the functional characteristics of respiratory cilia, namely CBF, in a
cohort of post-BMT recipients, with and without BO. We
have also studied the correlation of CBF with important
clinical parameters among this cohort.
Materials and methods
Survivors of bone marrow transplantation (BMT) often suffer from respiratory complications. These include conditioning toxicity, infective complications and bronchiliotis
obliterans (BO).1 BO is characterized histologically by
obliteration and destruction of lumen of respiratory
bronchioles by granulation tissue, mononuclear cell infiltration, and fibrosis. Clinically, it manifests itself as an irreversible obstructive defect affecting small airways, usually
Correspondence: Dr KWT Tsang, University Department of Medicine,
The University of Hong Kong, Queen Mary Hospital, Pokfulam Road,
Hong Kong SAR, China
Received 6 September 2000; accepted 7 March 2001
All allogeneic marrow recipients attending regular followup beyond 6 months after BMT were eligible for inclusion
in the study. Among 168 patients seen over a 2 month period, 36 were recruited with written informed consent. The
demographic and clinical characteristics of the cases are
outlined in Table 1. All the clinical charts were reviewed
for each patient. Lung function tests were performed
according to standard protocols, and results for FEV1,
FEF25–75 and FVC were expressed as percent of predicted
values.8 All patients had documented normal lung function
tests prior to BMT as part of standard work-up procedures.
Post-BMT BO and GVHD were diagnosed according to
standard criteria.6,9 CBF was measured, using a photometric
Ciliary function in BMT recipients
WY Au et al
1148
Table 1
Clinical details of 36 post-BMT patients
UPN
Sex
Age
Dx
FU
Cond
CBF
FEV1
FEF25–75
FEV1/FVC
15
42
61
80
106
123
127
161
184
192
198
200
220
238
239
244
254
256
279
332
359
361
365
373
413
416
425
444
450
453
455
456
460
471
475
477
M
M
F
F
M
M
F
F
M
F
M
F
F
M
F
M
M
F
F
F
F
F
M
M
F
M
M
M
F
F
M
M
F
F
M
M
28
33
42
35
32
45
38
22
18
32
35
35
43
29
32
41
27
35
26
44
41
33
29
17
37
32
56
29
35
47
45
41
22
34
31
46
CML
CML
AML
ALL
CML
CML
AML
APL
SAA
CML
CML
CML
AML
CML
AML
CML
CML
AML
ALL
CML
AML
CML
CML
CML
CML
AML
ALL
CML
CML
ALL
CML
CML
CML
HL
AML
AML
104.5
96.8
91.9
87.2
81.4
78.0
77.2
70.9
67.2
64.4
62.3
61.6
57.2
52.7
52.7
51.5
49.2
48.6
42.2
35.4
28.4
27.7
27.3
26.1
20.5
20.1
18.9
15.7
14.2
13.7
13.5
12.2
12.1
10.5
9.8
9.5
Bu-Cy
Cy-TBI
Bu-Cy-TBI
VP16-Cy-TBI
Cy-TBI
Bu-Cy
Bu-Cy-TBI
Bu-Cy-TBI
Cy-TLI
Cy-TBI
Bu-Cy
Bu-Cy
Bu-Cy
Bu-Cy
Bu-Cy-TBI
Bu-Cy
Cy-TBI
Bu-Cy
Cy-TBI
Bu-Cy
Bu-Cy
Bu-Cy
Bu-Cy
Bu-Cy
Bu-Cy
Bu-Cy
Cy-TBI
Bu-Cy
Bu-Cy
Cy-TBI
Bu-Cy
Bu-Cy
Bu-Cy
Cy-TBI
Bu-Cy-TBI
Cy-TBI
13.3
14.6
12.3
14.6
12.8
12.5
12.5
11.7
11.7
12.6
12.1
14.1
9.1
13.5
11.9
10.7
8.6
14.1
7.0
13.1
12.1
9.6
9.8
9.6
11.7
8.4
10.4
12.2
11.1
10.9
12.2
12.1
10.8
10.0
9.7
14.0
24
77
76
78
69
33
39
17
124
105
32
103
113
56
132
144
104
109
102
103
79
80
78
105
79
95
70
65
125
111
90
77
72
107
119
122
6
44
28
65
59
9
14
7
98
73
6
41
95
13
144
118
98
118
94
77
32
50
55
79
31
77
69
22
114
116
43
45
33
84
123
130
36
71
61
83
73
36
43
53
88
76
52
68
82
44
94
85
85
89
92
80
62
79
79
85
68
83
83
55
91
92
69
70
67
84
89
91
BO cGVHD
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
N
N
Y
N
N
N
N
N
N
Y
Y
Y
N
Y
N
Y
Y
N
N
N
Y
Y
N
N
N
Y
Y
Y
N
Y
Y
Y
Y
N
N
Y
Y
N
Y
Y
Y
Y
N
N
N
Y
N
Y
N
Y
N
Y
Y
Y
N
Y
Y
Y
N
N
Y
UPN = unique progression number; Cond = conditioning regimen; Dx = diagnosis; FU = follow-up time in months; CBF = ciliary beat frequency in Hertz;
FEV1 = forced expiratory volume in 1 s (% predicted); FEF = forced expiratory flow (% predicted); FVC = forced vital capacity; BO = bronchiolitis
obliterans; cGVHD = chronic graft-versus-host disease; M = male; F = female; AML = acute myeloid leukemia; CML = chronic myeloid leukemia;
ALL = acute lymphoblastic leukemia; HL = Hodgkin’s lymphoma; Bu = busulphan; Cy = cyclophosphamide; TBI = total body irradiation; Y = yes;
N = no.
technique as described previously.10 Briefly, nasal epithelium was obtained without anaesthetic by a cytology
brush from the inferior turbinate of patients, then re-suspended in 1.5 ml of medium 199 (Flow Laboratory, New
York, NY, USA). The ciliated epithelium was examined
using a Leica DM LB phase contrast microscope (with long
working distance lenses) which had a warm stage maintained at 37°C (Leica, Wetzlar, Germany). The beating
cilia, examined at 400×, were positioned to interrupt a light
source and this frequency of interruption was conveyed to a
MPV-COMBI photo-multiplier (Leica) and a custom-made
digital converter which translated this into ciliary beat frequency (Hz) as described previously.10 Light microscopy
examination was also performed to determine whether or
not there were any ciliary beating abnormalities such as
dyskinesia or immotility. The ciliary assessment results of
54 randomly recruited healthy volunteers who had similar
age and gender distribution were used as controls.
Bone Marrow Transplantation
Results
Patient and control characteristics
The median age of study patients and control subjects was
34.6 ± 8.5 (range 17–56) and 34.7 ± 11.0 (range 11–60),
respectively (Table 1). The male to female ratio was 1:1 in
the study group and 1.4:1 in the control group. Gender and
age distributions of the two groups were statistically comparable (P = 0.99 and P = 0.51, respectively). The underlying diagnoses for allogeneic BMT were acute myeloid leukemia (AML, n = 10), acute lymphoblastic leukemia (ALL,
n = 4), chronic myeloid leukemia (CML, n = 20), severe
aplastic anemia (n = 1) and Hodgkin’s lymphoma (n = 1).
Various conditioning regimens were used, including those
with TBI (n = 16) and without TBI (n = 20). Clinically, BO
was diagnosed in 18 BMT patients (50%) based on their
lung function characteristics: manifested small airway
Ciliary function in BMT recipients
WY Au et al
obstruction in the absence of other causes such as asthma
and COPD.11 Five cases were classified as severe (FEV1
⬍50% predicted), two cases as moderate (FEV1 51–65%
predicted) and 11 cases as mild (FEV1 66–80%
predicted).9,11 Treatment included inhalational steroids and
beta-agonist, as well as oral azathioprine and prednisolone.
Most of these patients suffered from cGVHD affecting
other parts of the body including the skin, oral mucosa and
liver. However, depending on the pattern of organ involvement, not all patients suffering from cGVHD had features
of BO. Likewise, some BO patients displayed no features of
cGVHD directed against other organs. None of the control
subjects were known to suffer from any systemic illness or
were on any regular medications.
Ciliary assessment and correlation analysis
The mean CBF in the study cases was 11.6 ± 1.84 Hz
(range 7.0–14.6), compared with 13.5 ± 1.45 Hz (range
9.6–17.0) in the control group (P ⬍ 0.001, Student’s t-test).
A scatter plot of the CBF vs age showed an overlap in
individual CBF between the BMT group of patients and
the control group (Figure 1). Within the BMT group, the
mean CBF for patients with cGVHD was significantly
lower than that of patients without cGVHD (10.8 ± 2.3 Hz
vs 12.1 ± 1.4 Hz, P = 0.048). There was a trend towards
lower mean CBF for patients with BO compared to those
without (10.8 ± 2.0 Hz vs 12.2 ± 1.4 Hz, P = 0.077). However, even the mean CBF among patients without BO was
significantly lower than that of the control subjects
(12.2 ± 1.4 Hz vs 13.5 ± 1.4 Hz, P = 0.001). Also within the
group of BMT recipients, significant correlation was found
between impaired CBF and low FEV1 (r = 0.26, P = 0.044);
low FEF25–75% (r = 0.295, P = 0.024); and low FEV1/FVC
18
Cillary beat frequency (Hz)
16
14
12
10
Control
8
BMT without
GVHD
BMT with
GVHD
6
10
20
30
40
50
60
70
Age
Figure 1 A scatterplot showing the relationship between ciliary beat
frequency and age for control subjects and recipients of bone marrow
transplantation.
ratio (r = 0.38, P = 0.009) (Spearman’s non-parametric test,
one tailed), which are indicators of disease severity for BO.
There was no correlation between CBF and age (r = 0.063,
P = 0.23). There was no significant difference in CBF
among men and women (P = 0.93) or patients with or without history of TBI (P = 0.958) (Student’s t-test).
1149
Discussion
Bronchiolitis obliterans is the most significant pulmonary
cause of morbidity and mortality among BMT survivors,
and accounts for over 30% of deaths.12,13 The incidence
after BMT is around 20%.14 Immune-mediated destruction
of small airways causing obstructive lung defect is the hallmark of the disease and the diagnosis of BO is usually
made on the appropriate clinical setting, supported by lung
function test results, with or without computed tomography
(CT) and histological changes. Serial lung function test
showing obstructive defect is the most sensitive method for
detecting early BO and for monitoring disease progress.15
Patients either run a static course with permanent residual
pulmonary defect, or a relentless deteriorating course lead
to respiratory failure.14 The treatment included steroids,
beta-agonists and immunosuppression, but end-stage
patients can only be salvaged by lung transplantation.16 As
an allo-immune disease, BO does not affect the native lung
after single lung transplantation, and rarely occurs after
autologous BMT.17 While T cells and macrophages have
been shown to be involved in the pathogenesis of postBMT BO in a murine model, there is evidence that
humoral-mediated immunity may also be involved.18
Probably due to a lack of equipment and research expertise, despite its high potential relevance in the increased susceptibility of respiratory infections, respiratory ciliary function had rarely been studied in BMT recipients. In the only
published study on 15 patients (including four autologous
BMT cases), CBF was reported to be within the normal
range, despite a high incidence of abnormalities on electron
microscopy.7 However, there was no control group in this
study for comparison of CBF. In addition, the authors
elected to regard ciliary beat frequency as normal when it
was ⭓8 Hz when the usually quoted normal range is 10–
16 Hz.19 The authors of this paper also reported ciliary
abnormalities including squamous metaplasia although this
is generally not regarded as a ‘ciliary’ abnormality in the
conventional assessment of respiratory mucosa. It is well
known that apparently even healthy subjects could have
high incidences of ciliary abnormalities. These include
complete absence or deficiency of outer or inner dynein
arms, nexin links, radial spokes, central sheath, inner
microtubules, and even the entire axoneme.20–22 The significance of isolated ciliary ultrastructural abnormalities
without functional deficit is, however, debatable.23
Our study showed, for the first time, that allogeneic BMT
was associated with ciliary dysfunction, especially for
patients suffering from GVHD and BO. Our positive results
might have been due to the inclusion of more cases with
BO and GVHD. The difference was also apparent when
compared with a matched control group, since the normal
range of CBF extended over a wide range, and a significant
Bone Marrow Transplantation
Ciliary function in BMT recipients
WY Au et al
1150
overlap occurs between normal and abnormal values.21,24
On the other hand, CBF abnormalities in BO patients after
lung transplantation have been extensively studied. Transient reversible ciliary dysfunction occurs in all patients who
have had lung transplantation.25 For patients with BO, however, the CBF remained depressed. The defect is confined
to the transplanted side and represents a form of chronic
rejection.26 Reduced mucociliary clearance will lead to
stagnation of respiratory mucus, which amasses cell debris
along with inhaled bacteria in the upper and lower respiratory tract. This could, in turn, create a vicious cycle of
infection, inflammation, airway destruction, and possibly
secondary ciliary dysfunction.27,28 In BMT patients, BO
occurs due to GVHD against the native lung. The incidence, clinical features and pathology of BO in the two
groups of transplantation patients are similar and may represent the same disease.29 It is, therefore, possible that
reduction in CBF is a primary abnormal finding in BMT
patients with BO. Chronic infection by common respiratory
pathogens such as Haemophilus influenzae and Pseudomonas aeruginosa, could also lead to impairment of ciliary
beat.19,30 Alternatively, it is also possible that the treatment
process for BMT recipients could be the cause of depressed
ciliary function in these patients. Clinically, it might be useful to screen post BMT patients for CBF abnormalities for
early prediction of BO before lung function abnormalities.
Patients with more severe CBF depression may also be predisposed to a more sinister clinical course of BO. Drugs
that stimulate mucociliary clearance and reduce local
inflammation may be tried early before inflammation and
fibrosis become well established.31,32 This hypothesis will
need to be prospectively tested by serial monitoring of a
larger cohort of patients who are patients at risk for the
development of BO after BMT.
Acknowledgements
This study was supported by a Hong Kong RGC grant.
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