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Adegunsoye A, Strek ME, Garrity E, Guzy R, Bag R. Comprehensive Care of the Lung Transplant Patient. Chest 2016; 152:150-164. [PMID: 27729262 DOI: 10.1016/j.chest.2016.10.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/27/2016] [Accepted: 10/01/2016] [Indexed: 12/20/2022] Open
Abstract
Lung transplantation has evolved into a life-saving treatment with improved quality of life for patients with end-stage respiratory failure unresponsive to other medical or surgical interventions. With improving survival rates, the number of lung transplant recipients with preexisting and posttransplant comorbidities that require attention continues to increase. A partnership between transplant and nontransplant care providers is necessary to deliver comprehensive and optimal care for transplant candidates and recipients. The goals of this partnership include timely referral and assistance with transplant evaluation, optimization of comorbidities and preparation for transplantation, management of common posttransplant medical comorbidities, immunization, screening for malignancy, and counseling for a healthy lifestyle to maximize the likelihood of a good outcome. We aim to provide an outline of the main aspects of the care of candidates for and recipients of lung transplants for nontransplant physicians and other care providers.
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Affiliation(s)
- Ayodeji Adegunsoye
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - Mary E Strek
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - Edward Garrity
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL; Lung Transplant Program, University of Chicago, Chicago, IL
| | - Robert Guzy
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL; Lung Transplant Program, University of Chicago, Chicago, IL
| | - Remzi Bag
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL; Lung Transplant Program, University of Chicago, Chicago, IL.
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52
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Wood RK. Esophageal Dysmotility, Gastro-esophageal Reflux Disease, and Lung Transplantation: What Is the Evidence? Curr Gastroenterol Rep 2016; 17:48. [PMID: 26454656 DOI: 10.1007/s11894-015-0474-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lung transplantation is an effective and life-prolonging therapy for patients with advanced lung disease (ALD). However, long-term patient survival following lung transplantation is primarily limited by development of an inflammatory and fibrotic process involving the lung allograft known as bronchiolitis obliterans syndrome (BOS). Although the precise cause of BOS remains uncertain and is likely multifactorial, chronic aspiration of gastro-duodenal contents is one possible contributing factor. Multiple small, cross-sectional studies performed over the past two decades have reported a high prevalence of gastro-esophageal reflux disease (GERD) and esophageal dysmotility in the ALD population and several investigations suggest the prevalence may increase following lung transplantation. More recent studies evaluating the direct effect of gastro-duodenal contents on airways have demonstrated a possible biologic link between GERD and BOS. Despite the recent advances in our understanding of BOS, further investigations are needed to establish GERD as a causative factor in its development. This review will discuss the existing literature that has identified an association of GERD with ALD and post-transplant populations, with a focus on recent advances in the field.
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Affiliation(s)
- Richard K Wood
- Division of Gastroenterology, Duke University Medical Center, DUMC 3662, Durham, NC, 27710, USA.
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53
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Patti MG, Vela MF, Odell DD, Richter JE, Fisichella PM, Vaezi MF. The Intersection of GERD, Aspiration, and Lung Transplantation. J Laparoendosc Adv Surg Tech A 2016; 26:501-5. [PMID: 27218671 DOI: 10.1089/lap.2016.0170] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Lung transplantation is a radical but life-saving treatment option for patients with end-stage lung diseases, such as idiopathic pulmonary fibrosis (IPF) and scleroderma. In light of the proposed association and controversy linking gastroesophageal reflux disease (GERD) to IPF and lung transplant outcome, the American Gastroenterological Association convened during the DDW in Washington in May 2015 a multidisciplinary group of experts in the field of GERD and lung transplantation to make considerations about the care of these patients based on available data and subsequent expert panel discussion at this symposium. The following topics were discussed: (1) pathophysiology of GERD-induced pulmonary symptoms, (2) GERD evaluation before and after lung transplantation, (3) outcome of lung transplantation for IPF and scleroderma, and (4) role of laparoscopic fundoplication before or after lung transplantation.
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Affiliation(s)
- Marco G Patti
- 1 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
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54
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Kopincova J, Calkovska A. Meconium-induced inflammation and surfactant inactivation: specifics of molecular mechanisms. Pediatr Res 2016; 79:514-21. [PMID: 26679157 DOI: 10.1038/pr.2015.265] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/03/2015] [Indexed: 12/21/2022]
Abstract
This review summarizes neonatal meconium aspiration syndrome in light of meconium-induced inflammation and inflammatory surfactant inactivation, related to both endogenous and therapeutic exogenous surfactant. The wide effect of meconium on surfactant properties is divided into three points. Direct effect of meconium on surfactant properties refers mainly to fragmentation of dipalmitoylphosphatidylcholine and other surfactant phospholipids together with cleavage of surfactant proteins. Initiation of inflammatory response due to activation of receptors by yet unspecified compounds involves complement and Toll-like receptor activation. A possible role of lung collectins, surfactant proteins A and D, which can exert both pro- and anti-inflammatory reactions, is discussed. Initiation of inflammatory response by specified compounds in meconium reflects inflammatory functioning of cytokines, bile acids, and phospholipases contained in meconium. Unifying sketch of many interconnections in all these actions aims at providing integrated picture of inflammatory surfactant inactivation.
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Affiliation(s)
- Jana Kopincova
- Department of Physiology and Martin Biomedical Centre, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Andrea Calkovska
- Department of Physiology and Martin Biomedical Centre, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
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55
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Chest wall strapping. An old physiology experiment with new relevance to small airways diseases. Ann Am Thorac Soc 2015; 11:1258-66. [PMID: 25172621 DOI: 10.1513/annalsats.201312-465oi] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Chest wall strapping (CWS) induces breathing at low lung volumes. Mild to moderate obesity can lead to similar changes in lung volumes, due to chest wall and abdominal restriction. Chest wall strapping is also conceptually similar to a mismatch between significantly oversized donor lungs transplanted into a recipient with a smaller chest cavity. Chest wall strapping increases lung elastic recoil, reduces pulmonary compliance, and substantially increases maximal expiratory flows. The interactions between elastic properties of the lung parenchyma and small airways are critical for pulmonary function. Chest wall strapping lowers residual volume and closing volume, likely from the interdependence between increased elastic recoil and airways, leading to greater radial distending forces on small airways and small airway dilation. Chronic obstructive pulmonary disease (COPD) and chronic rejection of the transplanted lung, bronchiolitis obliterans syndrome (BOS), are primarily diseases of the small airways, and are characterized by progressive obstruction and subsequent loss of small airways. In COPD, higher body mass index (BMI) (conceptually like being more tightly strapped) is associated with lower lung volumes, increased airway conductance, and lower risk of progression to emphysema or death. Likewise, in lung transplantation, oversized donor lungs have been linked to higher expiratory airflows, lower risk of bronchiolitis obliterans syndrome, and improved survival. This article reviews the physiology of chest wall strapping and explores how it could enhance the understanding or even the treatment of small airway diseases, such as COPD and bronchiolitis obliterans syndrome.
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56
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Management of pancreatic, gastrointestinal and liver complications in adult cystic fibrosis. Rev Mal Respir 2015; 32:566-85. [DOI: 10.1016/j.rmr.2014.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 12/09/2014] [Indexed: 01/27/2023]
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57
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Gulack BC, Meza JM, Lin SS, Hartwig MG, Davis RD. Reflux and Allograft Dysfunction: Is There a Connection? Thorac Surg Clin 2015; 25:97-105. [DOI: 10.1016/j.thorsurg.2014.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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58
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Pegna V, Mickevičius A, Tsang C. How useful is antireflux surgery in lung transplant patients with gastroesophageal reflux? MEDICINA-LITHUANIA 2014; 50:318-22. [PMID: 25541263 DOI: 10.1016/j.medici.2014.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 11/20/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Respiratory function deteriorates over time after lung transplant. Reflux disease with pulmonary complications is a possible cause of this decline. This case series we aim to assess whether respiratory function improves after Nissen fundoplication in lung transplant patients and if surgery reduces gastroesophageal reflux disease (GERD) symptoms and use of proton pump inhibitors (PPIs). MATERIALS AND METHODS A retrospective case series of lung transplant patients with reflux disease and Nissen fundoplication. Clinical symptoms, pH-metry data, use of PPIs were recorded before the procedure and up to 18 months postoperatively. The FEV1 values before and after Nissen fundoplication were recorded at 3 monthly intervals. Patients' satisfaction scores were recorded before operation and postoperatively. RESULTS A total of 64 lung transplant patients were selected. After Nissen fundoplication, the pH studies were done on 26 patients. The mean overall acid exposure fraction was 1.03% (P<0.05). FEV1 declined for 6 months postoperatively and then gradually improved. The comparison of FEV1 at 3 months preoperatively to 3 months postoperatively showed no significant difference (P=0.067) as well as at 6 months. A significant improvement in clinical GERD symptoms was achieved after antireflux surgery; however, the patients remained receiving PPIs. CONCLUSIONS NF has been established as a safe operation for lung transplant patients. Late Nissen fundoplication did not improve lung function significantly amongst lung transplanted patients; however, patients with symptomatic GERD may have benefited from Nissen fundoplication in terms of symptom relief. A multicenter randomized control trial is needed to assess the effect of early unselected reflux control on respiratory function and graft survival.
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Affiliation(s)
| | - Antanas Mickevičius
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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59
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Aramini B, D’Ovidio F. Gastroesophageal reflux disease and the lung transplant recipient. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13665-014-0092-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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60
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Launay D, Savale L, Berezne A, Le Pavec J, Hachulla E, Mouthon L, Sitbon O, Lambert B, Gaudric M, Jais X, Stephan F, Hatron PY, Lamblin N, Vignaux O, Cottin V, Farge D, Wallaert B, Guillevin L, Simonneau G, Mercier O, Fadel E, Dartevelle P, Humbert M, Mussot S. Lung and heart-lung transplantation for systemic sclerosis patients. A monocentric experience of 13 patients, review of the literature and position paper of a multidisciplinary Working Group. Presse Med 2014; 43:e345-63. [DOI: 10.1016/j.lpm.2014.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/23/2014] [Indexed: 12/14/2022] Open
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61
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Saito T, Liu M, Binnie M, Sato M, Hwang D, Azad S, Machuca TN, Zamel R, Waddell TK, Cypel M, Keshavjee S. Distinct expression patterns of alveolar "alarmins" in subtypes of chronic lung allograft dysfunction. Am J Transplant 2014; 14:1425-32. [PMID: 24787265 DOI: 10.1111/ajt.12718] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/27/2014] [Accepted: 02/17/2014] [Indexed: 01/25/2023]
Abstract
The long-term success of lung transplantation is limited by chronic lung allograft dysfunction (CLAD). The purpose of this study was to investigate the alveolar alarmin profiles in CLAD subtypes, restrictive allograft syndrome (RAS) and bronchiolitis obliterans syndrome (BOS). Bronchoalveolar lavage (BAL) samples were collected from 53 recipients who underwent double lung or heart-lung transplantation, including patients with RAS (n = 10), BOS (n = 18) and No CLAD (n = 25). Protein levels of alarmins such as S100A8, S100A9, S100A8/A9, S100A12, S100P, high-mobility group box 1 (HMGB1) and soluble receptor for advanced glycation end products (sRAGE) in BAL fluid were measured. RAS and BOS showed higher expressions of S100A8, S100A8/A9 and S100A12 compared with No CLAD (p < 0.0001, p < 0.0001, p < 0.0001 in RAS vs. No CLAD, p = 0.0006, p = 0.0044, p = 0.0086 in BOS vs. No CLAD, respectively). Moreover, RAS showed greater up-regulation of S100A9, S100A8/A9, S100A12, S100P and HMGB1 compared with BOS (p = 0.0094, p = 0.038, p = 0.041, p = 0.035 and p = 0.010, respectively). sRAGE did not show significant difference among the three groups (p = 0.174). Our results demonstrate distinct expression patterns of alveolar alarmins in RAS and BOS, suggesting that RAS and BOS may represent biologically different subtypes. Further refinements in biologic profiling will lead to a better understanding of CLAD.
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Affiliation(s)
- T Saito
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan
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62
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Neujahr DC, Uppal K, Force SD, Fernandez F, Lawrence C, Pickens A, Bag R, Lockard C, Kirk AD, Tran V, Lee K, Jones DP, Park Y. Bile acid aspiration associated with lung chemical profile linked to other biomarkers of injury after lung transplantation. Am J Transplant 2014; 14:841-8. [PMID: 24666830 PMCID: PMC5505513 DOI: 10.1111/ajt.12631] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 01/25/2023]
Abstract
Aspiration of gastrointestinal contents has been linked to worse outcomes following lung transplantation but uncertainty exists about underlying mechanisms. We applied high-resolution metabolomics of bronchoalveolar lavage fluid (BALF) in patients with episodic aspiration (defined by bile acids in the BALF) to identify potential metabolic changes associated with aspiration. Paired samples, one with bile acids and another without, from 29 stable lung transplant patients were studied. Liquid chromatography coupled to high-resolution mass spectroscopy was used to interrogate metabolomic contents of these samples. Data were obtained for 7068 ions representing intermediary metabolites, environmental agents and chemicals associated with microbial colonization. A substantial number (2302) differed between bile acid positive and negative samples when analyzed by false discovery rate at q = 0.01. These included pathways associated with microbial metabolism. Hierarchical cluster analysis defined clusters of chemicals associated with bile acid aspiration that were correlated to previously reported biomarkers of lung injury including T cell granzyme B level and the chemoattractants CXCL9 and CXCL10. These data specifically link bile acids presence in lung allografts to inflammatory pathways known to segregate with worsening allograft outcome, and provide additional mechanistic insight into the association between reflux and lung allograft injury.
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Affiliation(s)
- D. C. Neujahr
- Emory Transplant Center, Emory University, Atlanta, GA,Corresponding author: David C. Neujahr,
| | - K. Uppal
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA
| | - S. D. Force
- Emory Transplant Center, Emory University, Atlanta, GA
| | - F. Fernandez
- Emory Transplant Center, Emory University, Atlanta, GA
| | - C. Lawrence
- Emory Transplant Center, Emory University, Atlanta, GA
| | - A. Pickens
- Emory Transplant Center, Emory University, Atlanta, GA
| | - R. Bag
- Emory Transplant Center, Emory University, Atlanta, GA
| | - C. Lockard
- Emory Transplant Center, Emory University, Atlanta, GA
| | - A. D. Kirk
- Emory Transplant Center, Emory University, Atlanta, GA
| | - V. Tran
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA
| | - K. Lee
- Department of Industrial Engineering, Hanyang University, Hanyang, Korea
| | - D. P. Jones
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA
| | - Y. Park
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA,College of Pharmacy, Korea University, Sejong City, Korea
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63
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Vaquero Barrios JM, Redel Montero J, Santos Luna F. Comorbidities Impacting on Prognosis After Lung Transplant. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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64
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Comorbidities impacting on prognosis after lung transplant. Arch Bronconeumol 2013; 50:25-33. [PMID: 24355755 DOI: 10.1016/j.arbres.2013.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 11/17/2013] [Accepted: 11/19/2013] [Indexed: 12/15/2022]
Abstract
The aim of this review is to give an overview of the clinical circumstances presenting before lung transplant that may have negative repercussions on the long and short-term prognosis of the transplant. Methods for screening and diagnosis of common comorbidities with negative impact on the prognosis of the transplant are proposed, both for pulmonary and extrapulmonary diseases, and measures aimed at correcting these factors are discussed. Coordination and information exchange between referral centers and transplant centers would allow these comorbidities to be detected and corrected, with the aim of minimizing the risks and improving the life expectancy of transplant receivers.
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65
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Aspiration and allograft injury secondary to gastroesophageal reflux occur in the immediate post-lung transplantation period (prospective clinical trial). Ann Surg 2013; 258:705-11; discussion 711-2. [PMID: 24121257 DOI: 10.1097/sla.0b013e3182a6589b] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To provide novel pilot data to quantify reflux, aspiration, and allograft injury immediately post-lung transplantation. BACKGROUND Asymptomatic reflux/aspiration, associated with allograft dysfunction, occurs in lung transplant recipients. Early fundoplication has been advocated. Indications for surgery include elevated biomarkers of aspiration (bile salts) in bronchoalveolar lavage fluid (BALF). Measurements have been mostly documented after the immediate posttransplant period. We report the first prospective study of reflux/aspiration immediately posttransplantation to date. METHODS Lung transplant recipients were recruited over 12 months. At 1 month posttransplantation, patients completed a Reflux Symptom Index questionnaire and underwent objective assessment for reflux (manometry and pH/impedance). Testing was performed on maintenance proton pump inhibitor. BALF was assessed for pepsin, bile salts, interleukin-8 and neutrophils. RESULTS Eighteen lung transplant recipients, median age of 46 years (range: 22-59 years), were recruited. Eight of 18 patients had abnormal esophageal peristalsis. Five of 17 patients were positive on Reflux Symptom Index questionnaire. Twelve of 17 patients had reflux. Three patients exclusively had weakly acid reflux. Median acid exposure was 4.8% (range: 1%-79.9%) and median esophageal volume exposure was 1.6% (range: 0.7-5.5). There was a median of 72 reflux events (range: 27-147) per 24 hours. A correlation existed between Reflux Symptom Index score and proximal reflux (r = 0.533, P = 0.006). Pepsin was detected in 11 of 15 BALF samples signifying aspiration (median: 18 ng/mL; range: 0-43). Bile salts were undetectable, using spectrophotometry and rarely detectable using dual mass spectrometry (2/15) (levels 0.2 and 1.2 μmol/L). Lavage interleukin-8 and neutrophil levels were elevated. A correlation existed between proximal reflux events and neutrophilia (r = 0.52, P = 0.03). CONCLUSIONS Lung transplant recipients should be routinely assessed for reflux/aspiration within the first month posttransplant. Reflux/aspiration can be present early postoperatively. Pepsin was detected suggesting aspiration. Bile salts were rarely detected. Proximal reflux events correlated with neutrophilia, linked to allograft dysfunction and mortality. These results support the need for early assessment of reflux/aspiration, which may inform fundoplication.
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66
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Saito T, Takahashi H, Kaneda H, Binnie M, Azad S, Sato M, Waddell TK, Cypel M, Liu M, Keshavjee S. Impact of cytokine expression in the pre-implanted donor lung on the development of chronic lung allograft dysfunction subtypes. Am J Transplant 2013; 13:3192-201. [PMID: 24164971 DOI: 10.1111/ajt.12492] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 08/13/2013] [Accepted: 09/07/2013] [Indexed: 01/25/2023]
Abstract
The long-term success of lung transplantation continues to be challenged by the development of chronic lung allograft dysfunction (CLAD). The purpose of this study was to investigate the relationship between cytokine expression levels in pre-implanted donor lungs and the posttransplant development of CLAD and its subtypes, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Of 109 patients who underwent bilateral lung or heart-lung transplantation and survived for more than 3 months, 50 BOS, 21 RAS and 38 patients with No CLAD were identified by pulmonary function test results. Using donor lung tissue biopsies sampled from each patient, expression levels of IL-6, IL-1β, IL-8, IL-10, interferon-γ and tumor necrosis factor-α mRNA were measured. IL-6 expression levels were significantly higher in pre-implanted lungs of patients that ultimately developed BOS compared to RAS and No CLAD (p = 0.025 and 0.011, respectively). Cox regression analysis demonstrated an association between high IL-6 expression levels and BOS development (hazard ratio = 4.98; 95% confidence interval = 2.42-10.2, p < 0.001). In conclusion, high IL-6 mRNA expression levels in pre-implanted donor lungs were associated with the development of BOS, not RAS. This association further supports the contention that early graft injury impacts on both late graft function and early graft function.
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Affiliation(s)
- T Saito
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan
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67
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D'Ovidio F, Kaneda H, Chaparro C, Mura M, Lederer D, Di Angelo S, Takahashi H, Gutierrez C, Hutcheon M, Singer LG, Waddell TK, Floros J, Liu M, Keshavjee S. Pilot study exploring lung allograft surfactant protein A (SP-A) expression in association with lung transplant outcome. Am J Transplant 2013; 13:2722-9. [PMID: 24007361 DOI: 10.1111/ajt.12407] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 06/21/2013] [Accepted: 06/25/2013] [Indexed: 01/25/2023]
Abstract
Primary graft failure and chronic lung allograft dysfunction (CLAD) limit lung transplant long-term outcomes. Various lung diseases have been correlated with surfactant protein (SP) expression and polymorphisms. We sought to investigate the role of SP expression in lung allografts prior to implantation, in relation to posttransplant outcomes. The expression of SP-(A, B, C, D) mRNA was assayed in 42 allografts. Posttransplant assessments include pulmonary function tests, bronchoscopy, broncho-alveolar lavage fluid (BALF) and biopsies to determine allograft rejection. BALF was assayed for SP-A, SP-D in addition to cytokines IL-8, IL-12 and IL-2. The diagnosis of CLAD was evaluated 6 months after transplantation. Lung allografts with low SP-A mRNA expression prior to implantation reduced survival (Log-rank p < 0.0001). No association was noted for the other SPs. Allografts with low SP-A mRNA had greater IL-2 (p = 0.03) and IL-12 (p < 0.0001) in the BALF and a greater incidence of rejection episodes (p = 0.003). Levels of SP-A mRNA expression were associated with the SP-A2 polymorphisms (p = 0.015). Specifically, genotype 1A1A(0) was associated with lower SP-A mRNA expression (p < 0.05). Lung allografts with low levels of SP-A mRNA expression are associated with reduced survival. Lung allograft SP-A mRNA expression appears to be associated with SP-A gene polymorphisms.
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Affiliation(s)
- F D'Ovidio
- Lung Transplant Program, Columbia University Medical Centre, New York, NY
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68
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Allaix ME, Fisichella PM, Noth I, Mendez BM, Patti MG. The pulmonary side of reflux disease: from heartburn to lung fibrosis. J Gastrointest Surg 2013; 17:1526-35. [PMID: 23615806 DOI: 10.1007/s11605-013-2208-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 04/10/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the USA. Heartburn is the symptom most commonly associated with this disease, and the highly commercialized medical treatment directed toward relief of this symptom represents a 10-billion-dollar-per-year industry. DISCUSSION Unfortunately, there is often little awareness that GERD can be potentially a lethal disease as it can cause esophageal cancer. Furthermore, there is even less awareness about the relationship between GERD and respiratory disorders with the potential for severe morbidity and even mortality.
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Affiliation(s)
- Marco E Allaix
- Center for Esophageal Diseases, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
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69
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Pepsin concentrations are elevated in the bronchoalveolar lavage fluid of patients with idiopathic pulmonary fibrosis after lung transplantation. J Surg Res 2013; 185:e101-8. [PMID: 23845868 DOI: 10.1016/j.jss.2013.06.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Aspiration of gastroesophageal refluxate has been implicated in the pathogenesis of idiopathic pulmonary fibrosis (IPF) and the progression of bronchiolitis obliterans syndrome after lung transplantation. The goals of the present study were to identify lung transplant patients at the greatest risk of aspiration and to investigate the causative factors. MATERIALS AND METHODS From September 2009 to November 2011, 252 bronchoalveolar lavage fluid (BALF) samples were collected from 100 lung transplant patients. The BALF pepsin concentrations and the results of transbronchial biopsy, esophageal function testing, barium swallow, and gastric emptying scan were compared among those with the most common end-stage lung diseases requiring lung transplantation: IPF, chronic obstructive pulmonary disease, cystic fibrosis, and α1-antitrypsin deficiency. RESULTS Patients with IPF had higher BALF pepsin concentrations and a greater frequency of acute rejection than those with α1-antitrypsin deficiency, cystic fibrosis, or chronic obstructive pulmonary disease (P = 0.037). Moreover, the BALF pepsin concentrations correlated negatively with a lower esophageal sphincter pressure and distal esophageal amplitude; negatively with distal esophageal amplitude and positively with total esophageal acid time, longest reflux episode, and DeMeester score in those with chronic obstructive pulmonary disease; and negatively with the upright acid clearance time in those with IPF. CONCLUSIONS Our results suggest that patients with IPF after lung transplantation are at increased risk of aspiration and a greater frequency of acute rejection episodes, and that the risk factors for aspiration might be different among those with the most common end-stage lung diseases who have undergone lung transplantation. These results support the role of evaluating the BALF for markers of aspiration in assessing lung transplant patients as candidates for antireflux surgery.
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70
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Weigt SS, DerHovanessian A, Wallace WD, Lynch JP, Belperio JA. Bronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation. Semin Respir Crit Care Med 2013; 34:336-51. [PMID: 23821508 PMCID: PMC4768744 DOI: 10.1055/s-0033-1348467] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. Clinically, BOS manifests as airway obstruction and dyspnea that are classically progressive and ultimately fatal; however, the course is highly variable, and distinguishable phenotypes may exist. There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.
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Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
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71
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Kennedy VE, Todd JL, Palmer SM. Bronchoalveolar lavage as a tool to predict, diagnose and understand bronchiolitis obliterans syndrome. Am J Transplant 2013; 13:552-61. [PMID: 23356456 PMCID: PMC3582805 DOI: 10.1111/ajt.12091] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/03/2012] [Accepted: 12/08/2012] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS), a condition of irreversible small airway fibrosis, is the principal factor limiting long-term survival after lung transplantation. Bronchoscopy and bronchoalveolar lavage (BAL), techniques central to lung transplant clinical practice, provide a unique opportunity to interrogate the lung allograft during BOS development and identify potential disease mechanisms or biomarkers. Over the past 20 years, numerous studies have evaluated the BAL cellular composition, cytokine profiles and protein constituents in lung transplant recipients with BOS. To date, however, no summative evaluation of this literature has been reported. We developed and applied objective criteria to qualitatively rank the strength of associations between BAL parameters and BOS in order to provide a comprehensive and systematic assessment of the literature. Our analysis indicates that several BAL parameters, including neutrophil count, interleukin-8, alpha defensins and MMP-9, demonstrate highly replicable associations with BOS. Additionally, we suggest that considerable opportunity exists to increase the knowledge gained from BAL analyses in BOS through increased sample sizes, covariant adjustment and standardization of the BAL technique. Further efforts to leverage analysis of BAL constituents in BOS may offer great potential to provide additional in-depth and mechanistic insights into the pathogenesis of this complex disease.
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Affiliation(s)
- Vanessa E. Kennedy
- Division of Pulmonary, Allergy and Critical Care Medicine- Duke University Medical Center, Durham, NC
| | - Jamie L. Todd
- Division of Pulmonary, Allergy and Critical Care Medicine- Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | - Scott M. Palmer
- Division of Pulmonary, Allergy and Critical Care Medicine- Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
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72
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Monforte V, López-Sánchez A, Zurbano F, Ussetti P, Solé A, Casals C, Cifrian J, de Pablos A, Bravo C, Román A. Prophylaxis with nebulized liposomal amphotericin B for Aspergillus infection in lung transplant patients does not cause changes in the lipid content of pulmonary surfactant. J Heart Lung Transplant 2013; 32:313-9. [DOI: 10.1016/j.healun.2012.11.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 10/30/2012] [Accepted: 11/10/2012] [Indexed: 12/27/2022] Open
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73
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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74
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Karbasi A, Goosheh H, Aliannejad R, Saber H, Salehi M, Jafari M, Imani S, Saburi A, Ghanei M. Pepsin and bile acid concentrations in sputum of mustard gas exposed patients. Saudi J Gastroenterol 2013; 19:121-5. [PMID: 23680709 PMCID: PMC3709374 DOI: 10.4103/1319-3767.111954] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIM Gastro-esophageal reflux has been suggested to be associated with several pulmonary complications such as asthma, and post-transplant bronchiolitis obliterans (BO). Pepsin or bile salts in the sputum is shown to be an optimal molecular marker of gastric contents macro/micro aspiration. In this study, we investigated sputum pepsin as a marker of micro-aspiration in sulfur mustard (SM) exposed cases compared to healthy controls. MATERIALS AND METHODS In a case controlled study, 26 cases with BO and 12 matched healthy controls were recruited and all cases were symptomatic and their exposure to SM was previously documented during Iran-Iraq conflict. Pepsin levels in sputum and total bile acids were measured using enzymatic assay. The severity of respiratory disorder was categorized based upon the spirometric values. RESULT The average concentration of pepsin in sputum was higher in the case group (0.29 ± 0.23) compared with healthy subjects (0.13 ± 0.07; P ± 0.003). Moreover, the average concentration of bile acids in the sputum cases was not significantly different in comparison to the controls ( P = 0.5). CONCLUSION Higher pepsin concentrations in sputum of SM exposed patients compared with healthy control subjects indicate the occurrence of significantly more gastric micro-aspiration in SM exposed patients.
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Affiliation(s)
- Ashraf Karbasi
- Baqiyatallah Research Center of Gastroentrology and Liver diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hassan Goosheh
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Rasoul Aliannejad
- Respiratory Diseases and TB Research Center of Guilan University of Medical Science, Razi Hospital, Rasht, Iran,Advanced Thoracic Research Centre, Tehran University of Medical Sciences, Iran
| | - Hamid Saber
- Pulmonary Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Salehi
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mahvash Jafari
- Department of Biochemistry, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Saber Imani
- Young Researchers Club and Elites, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Amin Saburi
- Health Research Center, Baqiyatallah university of medical sciences, Tehran, Iran
| | - Mostafa Ghanei
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran,Address for correspondence: Dr. Mostafa Ghanei, Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. E-mail:
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75
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Abstract
It is increasingly accepted that the effects of gastro-oesophageal reflux are not limited to the gastrointestinal tract. The adjacent respiratory structures are also at risk from material ejected from the proximal oesophagus as a result of the failure of anatomical and physiological barriers. There is evidence of the influence of reflux on several respiratory and otorhinological conditions and although in many cases the precise mechanism has yet to be elucidated, the association alone opens potential novel avenues of therapy to clinicians struggling to treat patients with apparently intractable respiratory complaints. This review provides a description of the airway reflux syndrome, its effects on the lung and current and future therapeutic options.
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Affiliation(s)
- Ian D Molyneux
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
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76
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Karli R, Alacam H, Duran L, Alici O, Kati C, Karli A, Guzel A. Analysis of the protective biochemical and pathologic effects of aminoguanidine on an experimental aspiration pneumonitis model induced by bile acids. Curr Ther Res Clin Exp 2012; 73:207-19. [PMID: 24653522 DOI: 10.1016/j.curtheres.2012.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) is a common clinical pathology detected in childhood. Bile acids (BAs) are present in reflux and cause various pathologies in the esophagus, the larynx, and the lungs. OBJECTIVE We aimed to show if aminoguanidine (AG) contributes to the biochemical and histopathologic treatment of experimental aspiration pneumonitis induced by BAs. METHODS Twenty-eight female Sprague Dawley rats were used. There were 4 groups in the study: (1) group aspirated with 0.9% saline (n = 7), (2) group aspirated with 0.9% saline and treated with AG (n = 7), (3) group aspirated with a solution of 10 mg/kg taurocholic acid and 5 mg/kg taurochenodeoxycholate (n = 7), and (4) group aspirated with BA and treated with AG (n = 7). The saline and BA solutions were administered as 1 mL/kg intratracheally. The AG was administered intraperitoneally twice a day at a 150 mg/kg dose for 7 days. The different histopathologic and biochemical parameters were analyzed. RESULTS Clara cell protein 16 and malondialdehyde levels were found to be significantly higher in the BA group than in the group where saline was administered; however, they were significantly lower in the BA + AG group than in the BA group. The total superoxide dismutase activity decreased significantly in the BA group compared with the group where saline was administered. A significant increase in superoxide dismutase activity was observed in the BA + AG group when compared with the group where only BA was administered. When the group where BA was administered solely was compared with the group where saline was administered, peribronchial inflammatory cell infiltration, alveolar septal infiltration, alveolar histiocytes, interstitial fibrosis, and granuloma were significantly higher in the BA group than in the saline group. When the BA + AG group was compared with the BA group, peribronchial inflammatory cell infiltration, alveolar septal infiltration, alveolar histiocytes, interstitial fibrosis, and granuloma were found to be significantly lower. CONCLUSIONS Oxidant stress increases and antioxidant capacity decreases in pneumonitis induced by BAs. AG administration as an antioxidant helps in recovery, both biochemically and histopathologically. Consequently, AG seems to be an alternative that should be considered in a conservative approach to treating aspiration pneumonitis.
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Affiliation(s)
- Rifat Karli
- Department of Otorhinolaryngology, Ondokuz Mayis University, Samsun, Turkey
| | - Hasan Alacam
- Department of Medical Biochemistry, Ondokuz Mayis University, Samsun, Turkey
| | - Latif Duran
- Department of Emergency Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Omer Alici
- Department of Pathology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Celal Kati
- Department of Otorhinolaryngology, Ondokuz Mayis University, Samsun, Turkey
| | - Arzu Karli
- Department of Pediatric Infection, Ondokuz Mayis University, Samsun, Turkey
| | - Ahmet Guzel
- Department of Pediatrics, Ondokuz Mayis University, Samsun, Turkey
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77
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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78
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Mendez BM, Davis CS, Weber C, Joehl RJ, Fisichella PM. Gastroesophageal reflux disease in lung transplant patients with cystic fibrosis. Am J Surg 2012; 204:e21-6. [PMID: 22921151 DOI: 10.1016/j.amjsurg.2012.07.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 07/10/2012] [Accepted: 07/10/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) in lung transplant patients is being increasingly investigated because of its reported association with chronic rejection. However, information concerning the characteristics of GERD in cystic fibrosis (CF) patients is scarce. METHODS We compared esophageal pH monitoring, manometry, gastric emptying studies, and barium swallow of 10 lung transplant patients with CF with those of 78 lung transplant patients with other end-stage pulmonary diseases. RESULTS In lung transplant patients with CF, the prevalence of GERD was 90% (vs 54% controls, P = .04), of whom 70% had proximal reflux (vs 29% controls, P = .02). CONCLUSIONS Lung transplant patients with CF have a significantly higher prevalence and proximal extent of GERD than do other lung transplant recipients. These data suggest that CF patients in particular should be routinely screened for GERD after transplantation to identify those who may benefit from antireflux surgery, especially given the risks of GERD-related aspiration and chronic allograft injury.
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Affiliation(s)
- Bernardino M Mendez
- Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL 60153, USA
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79
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Zhangxue H, Min G, Jinning Z, Yuan S, li W, Huapei S, Rui L, Chunyu Z. Glycochenodeoxycholate induces rat alveolar epithelial type II cell death and inhibits surfactant secretion in vitro. Free Radic Biol Med 2012; 53:122-8. [PMID: 22569305 DOI: 10.1016/j.freeradbiomed.2012.04.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 04/01/2012] [Accepted: 04/09/2012] [Indexed: 12/14/2022]
Abstract
Bile acid-induced lung injury has become an important topic for neonatologists after the discovery of a high incidence of infant respiratory distress syndrome complicated from maternal intrahepatic cholestasis. To explore the molecular pathway of bile acid-induced lung injury, we investigated the cytotoxicity of the glycochenodeoxycholate (GCDC) to alveolar epithelial type II cells (AECII), as the main component of bile acid. The results demonstrated that glycochenodeoxycholate induced oxidative stress, mitochondrial damage, and increased caspase activity in the primary cultured AECII. Moreover, ROS scavengers and caspase inhibitors could rescue cell death induced by GCDC in rat AECII. Our results also indicated that GCDC inhibited AECII surfactant secretion. In conclusion, this study suggested that cell death prevention and cell therapy should be considered as therapeutic strategies for infant respiratory distress syndrome complicated from maternal intrahepatic cholestasis.
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Affiliation(s)
- Hu Zhangxue
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing 400042, China.
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80
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Fisichella PM, Davis CS, Kovacs EJ. A review of the role of GERD-induced aspiration after lung transplantation. Surg Endosc 2012; 26:1201-4. [PMID: 22083335 PMCID: PMC3690196 DOI: 10.1007/s00464-011-2037-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 09/18/2011] [Indexed: 01/06/2023]
Abstract
The increased prevalence of gastroesophageal reflux disease (GERD) in lung transplantation patients has been established; however, many questions persist regarding the relationship of GERD to aspiration and its potential to induce pulmonary allograft failure. Moreover, the biological implications of aspiration in lung transplantation have yet to be fully elucidated. The goal of this review was to assess the relationship between GERD and aspiration, focusing on the role of these events in the development of allograft injury after lung transplantation.
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Affiliation(s)
- P Marco Fisichella
- Department of Surgery, Swallowing Center, Loyola University Medical Center, 2160 South 1st Ave., Maywood, IL 60153, USA.
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81
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Aseeri A, Brodlie M, Lordan J, Corris P, Pearson J, Ward C, Manning N. Bile acids are present in the lower airways of people with cystic fibrosis. Am J Respir Crit Care Med 2012; 185:463. [PMID: 22336686 DOI: 10.1164/ajrccm.185.4.463] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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82
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Fisichella PM, Davis CS, Lowery E, Pittman M, Gagermeier J, Love RB, Kovacs EJ. Pulmonary immune changes early after laparoscopic antireflux surgery in lung transplant patients with gastroesophageal reflux disease. J Surg Res 2012; 177:e65-73. [PMID: 22537841 DOI: 10.1016/j.jss.2012.03.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/20/2012] [Accepted: 03/28/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The biologic mechanisms by which laparoscopic antireflux surgery (LARS) might influence the inflammatory process leading to bronchiolitis obliterans syndrome are unknown. We hypothesized that LARS alters the pulmonary immune profile in lung transplant patients with gastroesophageal reflux disease. METHODS In 8 lung transplant patients with gastroesophageal reflux disease, we quantified and compared the pulmonary leukocyte differential and the concentration of inflammatory mediators in the bronchoalveolar lavage fluid (BALF) 4 weeks before LARS, 4 weeks after LARS, and 12 months after lung transplantation. Freedom from bronchiolitis obliterans syndrome (graded 1-3 according to the International Society of Heart and Lung Transplantation guidelines), forced expiratory volume in 1 second trends, and survival were also examined. RESULTS At 4 weeks after LARS, the percentages of neutrophils and lymphocytes in the BALF were reduced (from 6.6% to 2.8%, P = 0.049, and from 10.4% to 2.4%, P = 0.163, respectively). The percentage of macrophages increased (from 74.8% to 94.6%, P = 0.077). Finally, the BALF concentration of myeloperoxide and interleukin-1β tended to decrease (from 2109 to 1033 U/mg, P = 0.063, and from 4.1 to 0 pg/mg protein, P = 0.031, respectively), and the concentrations of interleukin-13 and interferon-γ tended to increase (from 7.6 to 30.4 pg/mg protein, P = 0.078 and from 0 to 159.5 pg/mg protein, P = 0.031, respectively). These trends were typically similar at 12 months after transplantation. At a mean follow-up of 19.7 months, the survival rate was 75% and the freedom from bronchiolitis obliterans syndrome was 75%. Overall, the forced expiratory volume in 1 second remained stable during the first year after transplantation. CONCLUSIONS Our preliminary study has demonstrated that LARS can restore the physiologic balance of pulmonary leukocyte populations and that the BALF concentration of pro-inflammatory mediators is altered early after LARS. These results suggest that LARS could modulate the pulmonary inflammatory milieu in lung transplant patients with gastroesophageal reflux disease.
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Affiliation(s)
- P Marco Fisichella
- Department of Surgery, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois, USA.
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83
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Abstract
The ICU period is only one time point among many in the complex, multidisciplinary postoperative management required for patient survival and improved QOL. The care required on step-down units and after discharge to home each has unique care aspects that impact successful patient outcomes.
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Affiliation(s)
- Elisabeth L George
- Advanced Practice Nurse Critical Care, Department of Nursing, University of Pittsburgh Medical Center-Presbyterian Shadyside, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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84
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Tsai HC, Lin FC, Chen YC, Chang SC. The role of total bile acid in oral secretions in ventilator-associated pneumonia. J Crit Care 2012; 27:526.e1-6. [PMID: 22300490 DOI: 10.1016/j.jcrc.2011.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/14/2011] [Accepted: 12/08/2011] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study was to investigate the role of inflammatory biomarkers and total bile acid (TBA) in oral secretions in the development of ventilator-associated pneumonia (VAP). MATERIALS This prospective study was conducted in an intensive care unit. Oral secretions were collected from mechanically ventilated patients who met the selection criteria for VAP prevention protocol. The levels of interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor α, soluble intercellular adhesion molecule-1, monocyte chemoattractant protein-1, C-reactive protein, surfactant protein D, and TBA in oral secretions were measured and compared between the patients with and those without VAP. RESULTS Thirty-nine patients with and 39 patients without VAP were studied. The levels of inflammatory biomarkers in oral secretions showed no significant difference between the 2 groups. However, the patients with VAP had significantly higher values of TBA in oral secretions than did those without VAP (median and 25th-75th interquartile range, 9.59 and 1.37-24.66 μmol/L vs 2.74 and 0.00-8.22 μmol/L; P < .003). No significant correlations were found between TBA and inflammatory biomarkers in oral secretions. CONCLUSIONS Duodenogastroesophageal reflux as evidenced by the presence of TBA in oral secretions is common in mechanically ventilated patients and may play a role in the development of VAP.
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Affiliation(s)
- Han-Chen Tsai
- Respiratory Care Unit, Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
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85
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Hoppo T, Jobe BA. Diagnosis and Management of GERD Before and After Lung Transplantation. Thorac Surg Clin 2011; 21:499-510. [DOI: 10.1016/j.thorsurg.2011.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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86
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Smith JA, Abdulqawi R, Houghton LA. GERD-related cough: pathophysiology and diagnostic approach. Curr Gastroenterol Rep 2011; 13:247-56. [PMID: 21465223 DOI: 10.1007/s11894-011-0192-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic cough is a common problem resulting in significant impairment of quality of life. Along with cough variant asthma and nasal disease, gastroesophageal reflux is considered one of three main causes of cough. Despite this, acid suppression therapy is often far from effective. This review aims to explore whether reflux can lead to cough, the circumstances in which this is most likely to occur, and the potential mechanisms linking these processes. Particular mechanisms to be explored include laryngopharyngeal reflux, microaspiration, and neuronal cross-organ sensitization. Finally, diagnostic approaches are considered.
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Affiliation(s)
- Jaclyn A Smith
- Respiratory Research Group, University of Manchester, ERC Building, Second Floor, Wythenshawe Hospital, Manchester M23 9LT, UK.
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87
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Oue K, Mukaisho KI, Higo T, Araki Y, Nishikawa M, Hattori T, Yamamoto G, Sugihara H. Histological examination of the relationship between respiratory disorders and repetitive microaspiration using a rat gastro-duodenal contents reflux model. Exp Anim 2011; 60:141-50. [PMID: 21512269 DOI: 10.1538/expanim.60.141] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Microaspiration due to gastroesophageal reflux (GER) has been suggested as a factor contributing to the development and exacerbation of several respiratory disorders. To explore the relationship between GER and respiratory disorders, we histologically examined the bilateral lungs of a rat gastroduodenal contents reflux model, which was previously used to investigate the histogenesis of Barrett's esophagus and esophageal carcinoma. GER was surgically induced in male Wistar rats. The bilateral lungs of the reflux rats were examined with hematoxylin and eosin (HE), PAS-Alcian blue, and Azan staining at 10 and 20 weeks after surgery. Immunohistochemical staining of CD68 and α-SMA was also performed. Aspiration pneumonia with severe peribronchiolar neutrophilic and lymphocytic infiltrates, goblet cell hyperplasia, prominence of blood vessels, and increased thickness of the smooth muscle layer were detected. Bronchiolitis obliterans (BO)-like lesions comprising granulation tissue with macrophages, spindle cells, and multinucleated giant cells in the lumen of respiratory bronchioles were observed in the bilateral lungs of the reflux animals. These findings suggest that the severe inflammation and the BO-like lesions may play a role in exacerbation of the forced expiratory volume in 1 second (FEV 1) in human cases. In conclusion, we speculate that repetitive microaspiration due to GER may contribute to the exacerbation of various respiratory diseases, particularly asthma and chronic obstructive pulmonary disease (COPD), and the development of BO syndrome following lung transplantation. The reflux model is a good tool for examining the causal relationships between GER and respiratory disorders.
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Affiliation(s)
- Keisuke Oue
- Department of Pathology, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
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88
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Eberlein M, Permutt S, Chahla MF, Bolukbas S, Nathan SD, Shlobin OA, Shelhamer JH, Reed RM, Pearse DB, Orens JB, Brower RG. Lung size mismatch in bilateral lung transplantation is associated with allograft function and bronchiolitis obliterans syndrome. Chest 2011; 141:451-460. [PMID: 21799025 DOI: 10.1378/chest.11-0767] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Size mismatch between donor lungs and a recipient thorax could affect the major determinants of maximal expiratory airflow: airway resistance, propensity of airways to collapse, and lung elastic recoil. METHODS A retrospective review of 159 adults who received bilateral lung transplants was performed. The predicted total lung capacity (pTLC) for donors and recipients was calculated based on sex and height. Size matching was represented using the following formula: pTLC ratio = donor pTLC / recipient pTLC. Patients were grouped according to those with a pTLC ratio > 1.0 (oversized) or those with a pTLC ratio ≤ 1.0 (undersized). Allograft function was analyzed in relation to the pTLC ratio and to recipient and donor predicted function. RESULTS The 96 patients in the oversized cohort had a mean pTLC ratio of 1.16 ± 0.13 vs 0.89 ± 0.09 in the 63 patients of the undersized group. At 1 to 6 months posttransplant, the patients in the oversized cohort had higher FEV(1)/FVC ratios (0.895 ± 0.13 vs 0.821 ± 0.13, P < .01) and lower time constant estimates of lung emptying (0.38 ± 0.2 vs 0.64 ± 0.4, P < .01) than patients in the undersized cohort. Although the FVCs expressed as % predicted for the recipient were not different between cohorts, the FVCs expressed as % predicted for the donor organ were lower in the oversized cohort compared with the undersized cohort (at 1-6 months, 52.4% ± 17.1% vs 65.3% ± 18.3%, P < .001). Kaplan-Meier estimates for the occurrence of bronchiolitis obliterans syndrome (BOS) showed that patients in the oversized cohort had a lower probability of BOS (P < .001). CONCLUSIONS A pTLC ratio > 1.0, suggestive of an oversized allograft, is associated with higher expiratory airflow capacity and a less frequent occurrence of BOS.
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Affiliation(s)
- Michael Eberlein
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD.
| | - Solbert Permutt
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Mayy F Chahla
- Division of Hospital Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Servet Bolukbas
- Department of Thoracic Surgery, Horst-Schmidt-Klinik, Wiesbaden, Germany
| | - Steven D Nathan
- Advanced Lung Disease Program, Inova Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Advanced Lung Disease Program, Inova Fairfax Hospital, Falls Church, VA
| | - James H Shelhamer
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, MD
| | - David B Pearse
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Roy G Brower
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
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89
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Fisichella PM, Davis CS, Gagermeier J, Dilling D, Alex CG, Dorfmeister JA, Kovacs EJ, Love RB, Gamelli RL. Laparoscopic antireflux surgery for gastroesophageal reflux disease after lung transplantation. J Surg Res 2011; 170:e279-86. [PMID: 21816422 DOI: 10.1016/j.jss.2011.05.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 05/12/2011] [Accepted: 05/24/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although gastroesophageal reflux disease (GERD) is highly prevalent in lung transplantation, the pathophysiology of GERD in these patients is unknown. We hypothesize that the pathophysiology of GERD after lung transplantation differs from that of a control population, and that the 30-d morbidity and mortality of laparoscopic antireflux surgery (LARS) are equivalent in both populations. METHODS We retrospectively compared the pathophysiology of GERD and the 30-d morbidity and mortality of 29 consecutive lung transplant patients with 23 consecutive patients without lung transplantation (control group), all of whom had LARS for GERD between November 2008 and May 2010. RESULTS Both groups had a similar prevalence of endoscopic esophagitis and Barrett's esophagus , comparable manometric profiles, and similar prevalence of abnormal peristalsis. However, hiatal hernia was more common in controls than in lung transplant patients (57% versus 24%; P = 0.04). Lung transplant patients had a higher prevalence and severity of proximal GERD (65% versus 33%; P = 0.04). The 30-d morbidity and mortality following LARS were similar in both groups regardless of the higher surgical risk of lung transplants (median ASA class: 3 versus 2 for controls, P < 0.001). CONCLUSIONS These results show that despite similar manometric profiles, lung transplant patients are more prone to proximal reflux than the general population with GERD; the prevalence of endoscopic esophagitis and Barrett's esophagus is the same in both groups of patients; a hiatal hernia is uncommon after lung transplantation; and the morbidity and mortality of LARS are the same for lung transplant patients as the general population with GERD.
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Affiliation(s)
- P Marco Fisichella
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois, USA.
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90
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Heterogeneity of chronic lung allograft dysfunction: Insights from protein expression in broncho alveolar lavage. J Heart Lung Transplant 2011; 30:667-73. [DOI: 10.1016/j.healun.2010.12.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 12/08/2010] [Accepted: 12/12/2010] [Indexed: 11/22/2022] Open
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91
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Abstract
In the last 45 years, lung transplantation has evolved from its status as a rare extreme form of surgical therapy for the treatment of advanced lung diseases to an accepted therapeutic option for select patients. Although pulmonary fibrosis and pulmonary vascular diseases are important indications for lung transplantation, only a small percentage of transplants are performed in patients with collagen vascular diseases. The reasons for this low number are multifactorial. This article reviews issues relevant to all lung transplant candidates and recipients as well as those specific to patients with autoimmune diseases.
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Affiliation(s)
- James C Lee
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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92
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Sims MW, Beers MF, Ahya VN, Kawut SM, Sims KD, Lederer DJ, Palmer SM, Wille K, Lama VN, Shah PD, Orens JB, Bhorade S, Crespo M, Weinacker A, Demissie E, Bellamy S, Christie JD, Ware LB. Effect of single vs bilateral lung transplantation on plasma surfactant protein D levels in idiopathic pulmonary fibrosis. Chest 2011; 140:489-496. [PMID: 21349925 DOI: 10.1378/chest.10-2065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Serum levels of surfactant protein D (SP-D) have been suggested as reflecting epithelial damage in acute lung injury, COPD, and idiopathic pulmonary fibrosis (IPF). However, little is known about SP-D levels in the setting of lung transplantation. METHODS We examined plasma SP-D levels in 104 subjects from a prospective, multicenter cohort study of lung allograft recipients. Plasma SP-D was measured by enzyme-linked immunosorbent assay prior to transplant and daily for 3 days after transplant. RESULTS Subjects undergoing transplant for IPF had higher baseline SP-D levels (median, 325 ng/mL) compared with subjects with cystic fibrosis, COPD, and pulmonary hypertension (median, 100, 80, and 82 ng/mL, respectively; P = .0001). Among subjects with IPF undergoing bilateral transplant, SP-D levels declined rapidly postoperatively. In contrast, SP-D levels in subjects undergoing single lung transplant for IPF remained significantly higher than those of bilateral allograft recipients. Among subjects undergoing single lung transplant for IPF, the development of primary graft dysfunction (PGD) was associated with a subsequent rise in SP-D levels, whereas SP-D levels in IPF subjects undergoing bilateral transplant declined, even in the presence of grade 3 PGD. Importantly, single lung allograft recipients without PGD had higher postoperative SP-D levels than bilateral allograft recipients with PGD. CONCLUSIONS Subjects undergoing lung transplant for IPF have significantly higher baseline plasma SP-D levels compared with those with other diagnoses. Plasma SP-D is likely a biomarker of the air-blood barrier integrity in the native IPF lung, but may be less useful as a biomarker of PGD after transplant.
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Affiliation(s)
- Michael W Sims
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.
| | - Michael F Beers
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Vivek N Ahya
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Steven M Kawut
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Karen D Sims
- Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - David J Lederer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York City, NY
| | - Scott M Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC
| | - Keith Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Ann Arbor, MI
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Pali D Shah
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville TN
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sangeeta Bhorade
- Division of Pulmonary and Critical Care Medicine, University of Chicago Medical Center, Chicago, IL
| | - Maria Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ann Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ejigayehu Demissie
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Scarlett Bellamy
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville TN
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93
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Mertens V, Blondeau K, Van Oudenhove L, Vanaudenaerde B, Vos R, Farre R, Pauwels A, Verleden G, Van Raemdonck D, Sifrim D, Dupont LJ. Bile acids aspiration reduces survival in lung transplant recipients with BOS despite azithromycin. Am J Transplant 2011; 11:329-35. [PMID: 21272237 DOI: 10.1111/j.1600-6143.2010.03380.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Azithromycin (AZM) improved bronchiolitis obliterans syndrome (BOS) and reduced aspiration in lung transplant (LTx) recipients. We hypothesize that AZM could improve graft and overall survival more efficiently in LTx patients with BOS who have bile acid (BA) aspiration by protecting against the aspiration-induced progression of BOS. The goal was to compare FEV(1) (% baseline), BOS progression and overall survival in LTx recipients treated with AZM for BOS, both with versus without BA aspiration. Therefore, LTx recipients treated with AZM for BOS were recruited and broncho-alveolar lavage (BAL) samples were analyzed for the presence of BA and neutrophilia before the start of AZM treatment. Short-term effect of AZM on FEV(1) and BAL neutrophilia was assessed, progression of BOS and survival were followed-up for 3 years and results were compared between patients with/without BA aspiration. 19/37 LTx patients had BA in BAL. BA aspiration predisposed to a significantly worse outcome, in terms of decline in FEV(1) , progression of BOS ≥ 1 and survival. AZM does not seem to protect against the long-term allograft dysfunction caused by gastroesophageal reflux (GER) and aspiration and an additional treatment targeting aspiration may be indicated in those LTx patients.
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Affiliation(s)
- V Mertens
- Center for Gastroenterological Research, KULeuven, Belgium Laboratory of Pneumology, KULeuven, Belgium
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94
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Abstract
Lung transplantation has become a valuable treatment for end-stage pulmonary disorders in an attempt to improve quality of life and extend survival. Development of chronic rejection, also known as bronchiolitis obliterans syndrome (BOS), is responsible for the vast majority of deaths after lung transplantation. Up to 50% of lung transplant patients develop BOS within the first 5 years after transplantation. A high prevalence of gastroesophageal reflux and aspiration of gastric components has been described after lung transplantation. Reflux and aspiration have been implicated in the development of BOS and antireflux surgery has been proposed; however, the causal relationship with BOS and the impact of reflux in lung transplantation survival needs to be further elucidated.
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Affiliation(s)
- Veerle Mertens
- Center for Gastroenterological Research, KU Leuven, Leuven, Belgium
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95
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Meers CM, De Wever W, Verbeken E, Mertens V, Wauters S, De Vleeschauwer SI, Vos R, Vanaudenaerde BM, Verleden GM, Van Raemdonck DEM. A porcine model of acute lung injury by instillation of gastric fluid. J Surg Res 2010; 166:e195-204. [PMID: 21109258 DOI: 10.1016/j.jss.2010.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 10/04/2010] [Accepted: 10/15/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND About 15% of donor lungs are declined because of aspiration contributing to current organ shortage. The aim was to develop a porcine lung injury model by gastric juice (GJ) instillation to study different pretransplant treatment strategies. MATERIALS AND METHODS Pigs (n = 6/group) were anesthetized and monitored. At T0 bronchoalveolar lavage (BAL) was performed followed by instillation of 4 mL/kg GJ or saline solution (SAL). Hemodynamics, aerodynamics and oxygenation were recorded for two hours. Serum samples were collected. At T120 a second BAL was performed. CT scans of explanted, inflated lungs were taken, tissue samples were collected and wet/dry weight ratio (W/D) was calculated. Pepsin and bile acids were measured in BAL. IL-8, CRP and MMP-9 were measured in serum and in BAL. RESULT Oxygenation and lung compliance was lower in [GJ] versus [SAL] (P < 0.01 and P < 0.001, respectively). More consolidation areas were noticed on CT in GJ versus SAL (P < 0.01). Hemorrhage, edema and neutrophil inflammation were seen on histology in [GJ] (P < 0.01, P < 0.001, P < 0.001, respectively). BAL neutrophils, pepsin, bile acids, and IL-8 (P < 0.05) increased in [GJ]. W/D was higher in [GJ] versus SAL (P < 0.001). CONCLUSION Instillation of GJ in pig lungs caused acute lung injury with impaired oxygenation and increased inflammation in BAL, on histology, and on imaging. This model holds promise to assess the efficacy of a broad range of treatment strategies including ex vivo lung perfusion (EVLP).
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Affiliation(s)
- Caroline M Meers
- Laboratory for Experimental Thoracic Surgery, Katholieke Universiteit Leuven, Leuven, Belgium.
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96
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Davis CS, Jellish WS, Fisichella PM. Laparoscopic fundoplication with or without pyloroplasty in patients with gastroesophageal reflux disease after lung transplantation: how I do it. J Gastrointest Surg 2010; 14:1434-41. [PMID: 20499201 PMCID: PMC3066265 DOI: 10.1007/s11605-010-1233-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 05/11/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Several studies have confirmed that gastroesophageal reflux disease (GERD) in lung transplant patients is a risk factor for the development and progression of bronchiolitis obliterans syndrome (BOS), a form of rejection after lung transplantation. Moreover, numerous reports indicate that surgical correction of GERD may control the decline in lung function characteristic of BOS. Although laparoscopic fundoplication is an accepted treatment option for these patients with GERD, the surgical technique, which often includes a laparoscopic pyloroplasty, has not been standardized. METHODS The purpose of this article is to describe a step-by-step approach to the laparoscopic treatment of GERD in lung transplant patients. We also address specific technical concerns encountered in the surgical management of this high-risk patient population; we provide data on the safety of this operation; and we illustrate the evidence-based rationale for each technical step of the procedure.
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Affiliation(s)
- Christopher S. Davis
- Departments of Surgery and Anesthesia, Loyola University Medical Center, Maywood, IL, USA
| | - W. Scott Jellish
- Departments of Surgery and Anesthesia, Loyola University Medical Center, Maywood, IL, USA
| | - P. Marco Fisichella
- Departments of Surgery and Anesthesia, Loyola University Medical Center, Maywood, IL, USA, Swallowing Center, Department of Surgery, Stritch School of Medicine, Loyola University Medical Center, 2160 South First Avenue—Room 3226, Maywood, IL 60153, USA
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97
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Davis CS, Shankaran V, Kovacs EJ, Gagermeier J, Dilling D, Alex CG, Love RB, Sinacore J, Fisichella PM. Gastroesophageal reflux disease after lung transplantation: pathophysiology and implications for treatment. Surgery 2010; 148:737-44; discussion 744-5. [PMID: 20727564 DOI: 10.1016/j.surg.2010.07.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 07/07/2010] [Indexed: 01/11/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is thought to be a risk factor for the development or progression of chronic rejection after lung transplantation. However, the prevalence of GERD and its risk factors, including esophageal dysmotility, hiatal hernia and delayed gastric emptying after lung transplantation, are still unknown. In addition, the prevalence of Barrett's esophagus, a known complication of GERD, has not been determined in these patients. The purpose of this study was to determine the prevalence and extent of GERD, as well as the frequency of these risk factors and complications of GERD in lung transplant patients. METHODS Thirty-five consecutive patients underwent a combination of esophageal function testing, upper endoscopy, barium swallow, and gastric emptying scan after lung transplantation. RESULTS In this patient population, the prevalence of GERD was 51% and 22% in those who had been retransplanted. Of patients with GERD,36% had ineffective esophageal motility (IEM), compared with 6% of patients without GERD (P = .037). No patient demonstrated hiatal hernia on barium swallow. The prevalence of delayed gastric emptying was 36%. The prevalence of biopsy-confirmed Barrett's esophagus was 12%. CONCLUSION Our study shows that, after lung transplantation, more than half of patients had GERD, and that GERD was more common after retransplantation. IEM and delayed gastric emptying are frequent in patients with GERD. Hiatal hernia is rare. The prevalence of Barrett's esophagus is not negligible. We conclude that GERD is highly prevalent after lung transplantation, and that delayed gastric emptying and Barrett's esophagus should always be suspected after lung transplantation because they are common risks factors and complications of GERD.
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Affiliation(s)
- Christopher S Davis
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA
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98
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Oil red O stain of alveolar macrophages is an effective screening test for gastroesophageal reflux disease in lung transplant recipients. J Heart Lung Transplant 2010; 29:859-64. [DOI: 10.1016/j.healun.2010.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 03/08/2010] [Accepted: 03/18/2010] [Indexed: 11/21/2022] Open
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99
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Castor JM, Wood RK, Muir AJ, Palmer SM, Shimpi RA. Gastroesophageal reflux and altered motility in lung transplant rejection. Neurogastroenterol Motil 2010; 22:841-50. [PMID: 20507544 PMCID: PMC2911519 DOI: 10.1111/j.1365-2982.2010.01522.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lung transplantation has become an effective therapeutic option for selected patients with end stage lung disease. Long-term survival is limited by chronic rejection manifest as bronchiolitis obliterans syndrome (BOS). The aspiration of gastric contents has been implicated as a causative or additive factor leading to BOS. Gastroesophageal reflux (GER) and altered foregut motility are common both before and after lung transplantation. Further, the normal defense mechanisms against reflux are impaired in the allograft. Recent studies using biomarkers of aspiration have added to previous association studies to provide a growing body of evidence supporting the link between rejection and GER. Further, the addition of high-resolution manometry (HRM) and impedance technology to characterize bolus transit and the presence and extent of reflux regardless of pH might better identify at-risk patients. Although additional prospective studies are needed, fundoplication appears useful in the prevention or treatment of post-transplant BOS. PURPOSE This review will highlight the existing literature on the relationship of gastroesophageal reflux and altered motility to lung transplant rejection, particularly BOS. The article will conclude with a discussion of the evaluation and management of patients undergoing lung transplantation at our center.
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Affiliation(s)
- John M Castor
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Richard K. Wood
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Andrew J. Muir
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Scott M. Palmer
- Division of Pulmonary and Critical Care, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Rahul A. Shimpi
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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100
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Neujahr DC, Mohammed A, Ulukpo O, Force SD, Ramirez AM, Pelaez A, Lawrence EC, Larsen CP, Kirk AD. Surgical correction of gastroesophageal reflux in lung transplant patients is associated with decreased effector CD8 cells in lung lavages: a case series. Chest 2010; 138:937-43. [PMID: 20522573 DOI: 10.1378/chest.09-2888] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Lung transplantation is associated with a high incidence of gastroesophageal reflux disease (GERD). The presence of GERD is considered a risk factor for the subsequent development of obliterative bronchiolitis (OB), and surgical correction of GERD by gastric fundoplication (GF) may be associated with increased freedom from OB. The mechanisms underlying a protective effect from OB remain elusive. The objective of this study was to analyze the flow cytometric properties of BAL cells in patients who have undergone GF early after transplant. METHODS In a single-center lung transplant center, eight patients with GERD who were in the first transplant year underwent GF. Prior to and immediately following GF, BAL cells were analyzed by polychromatic flow cytometry. Spirometry was performed before and after GF. RESULTS GF was associated with a significant reduction in the frequency of BAL CD8 lymphocytes expressing the intracellular effector marker granzyme B, compared with the pre-GF levels. Twenty-six percent of CD8 cells were granzyme Bhi pre-GF compared with 12% of CD8 cells post-GF (range 8%-50% pre-GF, 2%-24% post-GF, P = .01). In contrast, GF was associated with a significant interval increase in the frequency of CD8 cells with an exhausted phenotype (granzyme Blo, CD127lo, PD1hi) from 12% of CD8 cells pre-GF to 24% post-GF (range 1.7%-24% pre-GF and 11%-47% post-GF, P = .05). No significant changes in spirometry were observed during the study interval. CONCLUSIONS Surgical correction of GF is associated with a decreased frequency of potentially injurious effector CD8 cells in the BAL of lung transplant recipients.
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Affiliation(s)
- David C Neujahr
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
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