Frontiers in medicine · 2026
Does bronchoalveolar lavage lymphocytosis predict prognosis in fibrotic hypersensitivity pneumonitis, and is this relationship influenced by low-dose immunomodulatory therapy at the time of BAL?
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Kaenmuang Punchalee, Danzo Fiammetta, Bax Simon, Hewitt Richard J, Kokosi Maria, Kouranos Vasileios, Chua Felix, George Peter M, Jenkins Gisli, Wells Athol U, Stock Carmel J W, Sestini Piersante, Renzoni Elisabetta A
Аннотация
BACKGROUND: Bronchoalveolar lavage (BAL) lymphocytosis is associated with improved prognosis in fibrotic hypersensitivity pneumonitis (fHP), although its prognostic value is unclear in patients receiving immunomodulatory treatment. We investigated whether treatment tapered to the lowest tolerated level at the time of BAL modifies associations with disease severity, one-year lung function, and transplant-free survival.
METHODS: We analysed 247 fHP patients undergoing BAL, including 162 untreated and 85 receiving immunomodulatory therapy at the time of BAL. Associations between BAL lymphocytosis and baseline composite physiologic index (CPI), one-year CPI change, and transplant-free survival were assessed using multivariable flexible parametric survival models incorporating treatment status and interaction terms, adjusted for covariates.
RESULTS: Mean age was 63 years, 43% male, 37% ever-smokers. Treated patients at the time of BAL were younger, with more severe disease (higher CPI). Mean BAL lymphocyte percentages were similar between two groups and inversely associated with baseline CPI in both. Higher BAL lymphocyte% were associated with more favourable CPI change in both untreated (-1.7 points per 10% increase; 95%CI -2.5--0.8, p < 0.0001) and treated patients at BAL (-2.0 points; 95% CI -3.1--0.9, p < 0.0001), with no treatment-by-BAL lymphocyte interaction (p = 0.64). Higher BAL lymphocyte% independently predicted lower mortality both in untreated (HR 0.87 per 10% increase, p = 0.036) and treated patients at the time of BAL (HR 0.78, p = 0.025), with no treatment-by-BAL lymphocyte interaction (p = 0.39).
CONCLUSION: BAL lymphocytosis was associated with less severe disease, favourable one-year CPI change and better survival, irrespective of background immunomodulatory therapy.
METHODS: We analysed 247 fHP patients undergoing BAL, including 162 untreated and 85 receiving immunomodulatory therapy at the time of BAL. Associations between BAL lymphocytosis and baseline composite physiologic index (CPI), one-year CPI change, and transplant-free survival were assessed using multivariable flexible parametric survival models incorporating treatment status and interaction terms, adjusted for covariates.
RESULTS: Mean age was 63 years, 43% male, 37% ever-smokers. Treated patients at the time of BAL were younger, with more severe disease (higher CPI). Mean BAL lymphocyte percentages were similar between two groups and inversely associated with baseline CPI in both. Higher BAL lymphocyte% were associated with more favourable CPI change in both untreated (-1.7 points per 10% increase; 95%CI -2.5--0.8, p < 0.0001) and treated patients at BAL (-2.0 points; 95% CI -3.1--0.9, p < 0.0001), with no treatment-by-BAL lymphocyte interaction (p = 0.64). Higher BAL lymphocyte% independently predicted lower mortality both in untreated (HR 0.87 per 10% increase, p = 0.036) and treated patients at the time of BAL (HR 0.78, p = 0.025), with no treatment-by-BAL lymphocyte interaction (p = 0.39).
CONCLUSION: BAL lymphocytosis was associated with less severe disease, favourable one-year CPI change and better survival, irrespective of background immunomodulatory therapy.