1
|
Yamamoto M, Kamal AN, Gabbard S, Clarke J, Gyawali CP, Leiman DA. Esophageal Function Testing Patterns in the Evaluation and Management of Lung Transplantation: Results of a National Survey. J Clin Gastroenterol 2024; 58:857-864. [PMID: 38047589 DOI: 10.1097/mcg.0000000000001955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/12/2023] [Indexed: 12/05/2023]
Abstract
GOALS We surveyed esophageal motility laboratories affiliated with adult pulmonary transplant centers to determine esophageal function testing (EFT) practices. BACKGROUND Gastroesophageal reflux and esophageal dysmotility are associated with worse lung transplant outcomes, yet no consensus guidelines for EFT exist in this population. STUDY A deidentified online survey was sent to gastrointestinal motility laboratory directors of 49 academic and community-affiliated medical centers that perform lung transplants. Practice characteristics, including annual lung transplant volume and institutional EFT practices pre-lung transplantation and post-lung transplantation were queried. Respondents were categorized by transplant volume into small and large programs based on median annual volume. RESULTS Among 35 respondents (71% response rate), the median annual transplant volume was 37, and there were 18 large programs. Institutional EFT protocols were used pretransplant by 24 programs (68.6%) and post-transplant by 12 programs (34.2%). Among small and large programs, 52.9% and 72.2% always obtained high-resolution manometry before transplant, respectively. Endoscopy before transplant was performed more often in small programs (n=17, 100%) compared with large programs (n=15,83.3%). Pretransplant endoscopy ( P =0.04), barium esophagram ( P <0.01), and high-resolution manometry ( P =0.04) were more common than post-transplant. In contrast, post-transplant reflux monitoring off-therapy was more common than pretransplant ( P =0.01). In general, pulmonologists direct referrals for EFT and gastroenterology consultation (n=28, 80.0%), with symptoms primarily prompting testing. CONCLUSIONS In the absence of established guidelines, substantial variability exists in pretransplant and post-transplant EFT, directed by pulmonologists. Standardized EFT protocols and gastroenterologist-directed management of esophageal dysfunction has potential to improve lung transplant outcomes.
Collapse
Affiliation(s)
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA
| | - Scott Gabbard
- Division of Gastroenterology, Cleveland Clinic, Cleveland, OH
| | - John Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - David A Leiman
- Division of Gastroenterology, Duke University
- Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
2
|
Lo WK, Muftah M, Goldberg HJ, Sharma N, Chan WW. Concurrent abnormal non-acid reflux is associated with additional chronic rejection risk in lung transplant patients with increased acid exposure. Dis Esophagus 2024; 37:doae020. [PMID: 38521967 DOI: 10.1093/dote/doae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/04/2024] [Indexed: 03/25/2024]
Abstract
Acid reflux has been associated with allograft injury and rejection in lung transplant patients; however, the pathogenic role of non-acid reflux remains debated. We aimed to evaluate the impact of concurrent abnormal non-acid reflux with acid reflux on chronic rejection in lung transplant patients with acid reflux. This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant combined impedance-pH study off acid suppression. Only subjects with acid exposure >4% were included. Non-acid reflux (pH > 4) episodes >27 was considered abnormal per prior normative studies. Chronic rejection was defined as chronic lung allograft dysfunction (CLAD) per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses were performed using Cox proportional hazards and Kaplan-Maier methods, with censoring at death, anti-reflux surgery, or last follow-up. In total, 68 subjects (28 abnormal/40 normal non-acid reflux) met inclusion criteria for the study. Baseline demographic/clinical characteristics were similar between groups. Among this cohort of patients with increased acid exposure, subjects with concurrent abnormal non-acid reflux had significantly higher risk of CLAD than those without on Kaplan-Meier analysis (log-ranked P = 0.0269). On Cox multivariable regression analysis controlling for body mass index, age at transplantation, and proton pump inhibitor use, concurrent abnormal non-acid reflux remained independently predictive of increased CLAD risk (hazard ratio 2.31, confidence interval: 1.03-5.19, P = 0.04). Presence of concurrent abnormal non-acid reflux in lung transplant subjects with increased acid exposure is associated with additional risk of chronic rejection. Non-acid reflux may also contribute to pathogenicity in lung allograft injury/rejection, supporting a potential role for impedance-based testing in this population.
Collapse
Affiliation(s)
- Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Division of Gastroenterology, Boston VA Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mayssan Muftah
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Hilary J Goldberg
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Nirmal Sharma
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Fernandez AM, Chan WW. Update on extraesophageal manifestations of gastroesophageal reflux. Curr Opin Gastroenterol 2024; 40:305-313. [PMID: 38662405 DOI: 10.1097/mog.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Symptoms/complications related to extraesophageal reflux (EER) are increasingly prevalent presentations and pose significant challenges for clinicians. We summarize and discuss clinical advances and developments in pathophysiology, testing and treatment algorithms of upper/lower airway manifestations of EER. RECENT FINDINGS Growing evidence supports likely multifactorial causes of laryngeal symptoms, including EER, oropharyngeal pathologies, allergic conditions, and cognitive-affective processes (brain-larynx interaction). Diagnostic paradigm for laryngopharyngeal reflux (LPR) is shifting towards a personalized approach with noninvasive strategies/prediction tools to risk-stratify patients for upfront reflux testing over empiric acid suppression trials. Management should be multipronged to include antireflux therapies and treatments targeting other causes. Lower airway complications of EER may result in lung dysfunction and poor transplant outcomes. Esophageal symptoms are often absent and routine esophageal/reflux testing to guide timely antireflux therapies may lead to improved outcomes. Modalities that leverage impedance technology may be important, given the potential role of nonacidic reflux. Novel impedance-based metrics such as mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index may provide adjunctive diagnostic values. SUMMARY Standardized approach to diagnosis/management of EER should include multidisciplinary care teams and consider different phenotypes, nonreflux contributors, and the complex gut-airway relationships. Prompt antireflux therapies after careful candidate selection may improve outcomes of these airway complications.
Collapse
Affiliation(s)
- Annel M Fernandez
- Department of Medicine, Brigham and Women's Hospital
- Harvard Medical School
| | - Walter W Chan
- Department of Medicine, Brigham and Women's Hospital
- Harvard Medical School
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Ramendra R, Duong A, Zhang CYK, Huszti E, Zhou X, Havlin J, Ghany R, Cypel M, Yeung JC, Keshavjee S, Sage AT, Martinu T. Airway pepsinogen A4 identifies lung transplant recipients with microaspiration and predicts chronic lung allograft dysfunction. J Heart Lung Transplant 2024; 43:973-982. [PMID: 38211836 DOI: 10.1016/j.healun.2024.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/04/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant. METHODS Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs. RESULTS PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4. CONCLUSIONS Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery.
Collapse
Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Allen Duong
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Xuanzi Zhou
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Wu R, Robayo V, Nguyen DT, Chan EY, Chihara R, Huang HJ, Graviss EA, Kim MP. Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients. Surg Endosc 2024; 38:2134-2141. [PMID: 38443500 DOI: 10.1007/s00464-024-10719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. METHODS We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. RESULTS Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). DISCUSSION The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.
Collapse
Affiliation(s)
- Rebecca Wu
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Edward Y Chan
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Howard J Huang
- Division of Pulmonary Critical Care, and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, FACS. 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
| | - Min P Kim
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA.
| |
Collapse
|
6
|
Klouda T, Ryan E M, Leonard JB, Freiberger D, Midyat L, Dahlberg S, Rosen R, Visner G. Gastrointestinal complications in pediatric lung transplant recipients: Incidence, risk factors, and effects on patient outcomes. Pediatr Transplant 2024; 28:e14665. [PMID: 38317336 DOI: 10.1111/petr.14665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/25/2023] [Accepted: 11/21/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Gastrointestinal (GI) complications in lung transplant recipients can occur any time during the post-operative period, leading to prolonged morbidity and mortality. Despite the negative association between GI complications and patient outcomes, little is known about their incidence and risk factors for their development in pediatric lung transplant recipients. METHODS We performed a retrospective chart review at one pediatric tertiary center to describe the frequency of GI complications in lung transplant recipients. We identified potential risk factors for the diagnosis of gastroparesis, gastroesophageal reflux disease (GERD) and aspiration in the post-transplant period. Lastly, we investigated the association of these complications with mortality and graft survival. RESULTS 84.3% of lung transplant recipients experienced at least one GI complication in the post-transplant period. Gastroparesis (52.9%), GERD (41.2%), and oropharyngeal dysphagia/laryngeal penetration (33.3%) were the most common complications diagnosed. Post-operative opioid exposure was a risk factor for gastroparesis, with the odds increasing 3.0% each day a patient was prescribed opioids (p = .021). The risk of death or retransplant in individuals who experienced gastroparesis was 2.7 times higher than those not diagnosed with gastroparesis (p = .027). CONCLUSION Exposure to opioids in the post-operative period is a risk factor for gastroparesis and a prolonged hospitalization placed patients at risk for aspiration. Gastroparesis was associated with increased patient mortality and graft failure, while aspiration and GERD had no effect on long term outcomes. Future prospective studies investigating the relationship between opioid use and the development of a gastroparesis are necessary to improve patient outcomes.
Collapse
Affiliation(s)
- Timothy Klouda
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Morgan Ryan E
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jessica Brie Leonard
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dawn Freiberger
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Levent Midyat
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne Dahlberg
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Latorre-Rodríguez AR, Razia D, Omar A, Bremner RM, Mittal SK. Pulmonary and esophageal function in lung transplantation: Fundamental principles and clinical application. Transplant Rev (Orlando) 2024; 38:100796. [PMID: 37840002 DOI: 10.1016/j.trre.2023.100796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/17/2023]
Abstract
The lungs and esophagus have a close anatomical and physiological relationship. Over the years, reflux-induced pulmonary injury has gained wider recognition, but the full effects of pulmonary disease on esophageal function are still unknown. Intrathoracic pressure dynamics potentially affect esophageal function, especially in patients with end-stage lung disease, both obstructive and restrictive. Lung transplantation is the only viable option for patients with end-stage pulmonary disease and has provided us with a unique opportunity to study these effects as transplantation restores the intrathoracic environment. Esophageal and foregut functional testing before and after transplantation provide insights into the pathophysiology of the foregut-pulmonary axis, such as how underlying pulmonary disease and intrathoracic pressure changes affect esophageal physiology. This review summarizes the available literature and shares the research experience of a lung transplant center, covering topics such as pre- and posttransplant foregut function, esophageal motility in lung transplant recipients, immune-mediated mechanisms of graft rejection associated with gastroesophageal reflux, and the role of antireflux surgery in this population.
Collapse
Affiliation(s)
| | - Deepika Razia
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
| |
Collapse
|
8
|
Jodorkovsky D, Katzka DA, Gyawali CP. A perspective on the clinical relevance of weak or nonacid reflux. Neurogastroenterol Motil 2023; 35:e14671. [PMID: 37702263 DOI: 10.1111/nmo.14671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Advances in ambulatory esophageal reflux monitoring that incorporated impedance electrodes to pH catheters have resulted in better characterization of retrograde bolus flow in the esophagus. With pH-impedance monitoring, in addition to acid reflux episodes identified by pH drops below 4.0, weakly acid reflux (WAR, pH 4-7) and nonacid reflux (NAR, pH >7.0) are also recognized, although both may be included under the umbrella term NAR. However, despite identification of ambulatory pH-impedance monitoring, data on clinical relevance and prognostic value of NAR are limited. The Lyon Consensus, an international expert review that defines conclusive metrics for gastroesophageal reflux disease (GERD), identifies NAR as "supportive" but not conclusive for GERD. PURPOSE This review provides perspectives on whether NAR fulfills three criteria for clinical relevance: whether NAR sufficiently explains pathogenesis of symptoms, whether it is associated with meaningful manifestations of GERD, and whether it can predict treatment efficacy.
Collapse
Affiliation(s)
- Daniela Jodorkovsky
- Division of Gastroenterology, Mount Sinai West & Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri, USA
| |
Collapse
|
9
|
Yang NY, Parish A, Posner S, Shimpi RA, Wood RK, Finn RT, Fisher DA, Hartwig MG, Klapper JA, Reynolds J, Niedzwiecki D, Leiman DA. Acid exposure time is sensitive for detecting gastroesophageal reflux disease and is associated with long-term survival after lung transplant. Dis Esophagus 2023; 36:doac114. [PMID: 36572397 DOI: 10.1093/dote/doac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/27/2022] [Accepted: 12/04/2022] [Indexed: 07/28/2023]
Abstract
Gastroesophageal reflux disease (GERD) is common in patients who have undergone lung transplantation and is associated with poorer outcomes, but guidelines are lacking to direct management strategies in this population. We assessed the diagnostic yield of impedance metrics compared to pH-metry alone for detecting GERD among lung transplant recipients and evaluated their association with clinical outcomes. We performed a retrospective cohort study of consecutive patients who underwent lung transplantation. Demographic data, acid exposure time (AET), number of reflux episodes, mean nocturnal baseline impedance (MNBI), post-reflux swallowing-induced peristaltic wave index (PSPWI), and clinical outcomes including mortality were collected. The relationship between GERD metrics and clinical outcomes was assessed using Wilcoxon signed-rank test and Fisher's exact test as appropriate. Of the 76 patients studied, 29 (38%) had GERD based on abnormal AET after lung transplantation. One (1.3%) patient had GERD based on elevated number of reflux episodes and abnormal distal MNBI detected GERD in 19 (26%) patients, resulting in 62% sensitivity and 94% specificity. Two (2.6%) patients had normal PSPWI. Patients with low distal MNBI had significantly decreased forced expiratory volume in 1 second (FEV1) at 3-year posttransplant compared to those without low distal MNBI (P = 0.03). Three-year survival was significantly worse among patients with elevated AET (66.7% vs. 89.1%, P = 0.03) but not with low distal MNBI (68.4% vs. 84.3%, P = 0.18). Abnormal AET is more sensitive for detecting GERD than other reflux metrics studied and is associated with survival, suggesting pH-metry alone may be sufficient to guide GERD management after lung transplant.
Collapse
Affiliation(s)
- Nancy Y Yang
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Shai Posner
- Albany Gastroenterology Consultants, Albany, NY, USA
| | - Rahul A Shimpi
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Richard K Wood
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - R Thomas Finn
- Division of Gastroenterology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John Reynolds
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| |
Collapse
|
10
|
Frankel A, Kellar T, Zahir F, Chambers D, Hopkins P, Gotley D. Laparoscopic fundoplication after lung transplantation does not appear to alter lung function trajectory. J Heart Lung Transplant 2023; 42:603-609. [PMID: 36609090 DOI: 10.1016/j.healun.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/14/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The primary aim of this study was to determine if allograft function in lung transplant (LTx) recipients improves or stabilizes after laparoscopic fundoplication (LF). The secondary aim was to examine the differences in forced expiratory volume in 1 second (FEV1) before and after LF for various subgroups to identify patients who obtained a superior respiratory outcome after LF, and potential predictive factors for this outcome. METHODS Retrospective analysis of consecutive LTx recipients undergoing LF at a single centre in Brisbane, Australia between 2004 and 2018. 149/431 proceeded to LF after clinical review and pH study. Regular pre- and post-fundoplication pulmonary function tests were collected from participants. Data were analyzed with linear mixed models, random intercept models, the Reliable Change Index (RCI), and graphical and visual analysis of the trajectory of FEV1. RESULTS There was 100% follow-up. After Bonferroni adjustment for multiple comparison was performed, none of the models demonstrated statistical significance. The Reliable Change Index showed one patient had a significant improvement in lung function across that time period, while nine had a significant reduction. The rate of change before and after LF was similar for the 132/149 patients for whom the first and last pre- and post-LF FEV1 values were available. A subset of patients had a considerable reduction in their FEV1 in the peri-operative period (i.e., a large difference between the first measurement post-LF and the final measurement pre-LF). CONCLUSION In the largest published cohort to date, LF performed in a high-volume center did not appear to alter the reduction in allograft function seen with time.
Collapse
Affiliation(s)
- Adam Frankel
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, The University of Queensland, Herston Queensland, Australia.
| | - Trina Kellar
- The Prince Charles Hospital, Chermside Queensland, Australia
| | - Farah Zahir
- QCIF Facility for Advanced Bioinformatics, Woolloongabba, Queensland, Australia
| | - Daniel Chambers
- Faculty of Medicine, The University of Queensland, Herston Queensland, Australia; The Prince Charles Hospital, Chermside Queensland, Australia
| | - Peter Hopkins
- Faculty of Medicine, The University of Queensland, Herston Queensland, Australia; The Prince Charles Hospital, Chermside Queensland, Australia
| | - David Gotley
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, The University of Queensland, Herston Queensland, Australia
| |
Collapse
|
11
|
Halitim P, Tissot A. [Chronic lung allograft dysfunction in 2022, past and updates]. Rev Mal Respir 2023; 40:324-334. [PMID: 36858879 DOI: 10.1016/j.rmr.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION While short-term results of lung transplantation have improved considerably, long-term survival remains below that achieved for other solid organ transplants. CURRENT KNOWLEDGE The main cause of late mortality is chronic lung allograft dysfunction (CLAD), which affects nearly half of the recipients 5 years after transplantation. Immunological and non-immune risk factors have been identified. These factors activate the innate and adaptive immune system, leading to lesional and altered wound-healing processes, which result in fibrosis affecting the small airways or interstitial tissue. Several phenotypes of CLAD have been identified based on respiratory function and imaging pattern. Aside from retransplantation, which is possible for only small number of patients, no treatment can reverse the CLAD process. PERSPECTIVES Current therapeutic research is focused on anti-fibrotic treatments and photopheresis. Basic research has identified numerous biomarkers that could prove to be relevant as therapeutic targets. CONCLUSION While the pathophysiological mechanisms of CLAD are better understood than before, a major therapeutic challenge remains.
Collapse
Affiliation(s)
- P Halitim
- Service de pneumologie et soins intensifs, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France; Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France
| | - A Tissot
- Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France.
| |
Collapse
|
12
|
Green CL, Gulack BC, Keshavjee S, Singer LG, McCurry K, Budev MM, Reece TL, Lidor AO, Palmer SM, Davis RD. Reflux Surgery in Lung Transplantation: A Multicenter Retrospective Study. Ann Thorac Surg 2023; 115:1024-1032. [PMID: 36216086 DOI: 10.1016/j.athoracsur.2022.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/06/2022] [Accepted: 09/26/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Aspiration has been associated with graft dysfunction after lung transplantation, leading some to advocate for selective use of fundoplication despite minimal data supporting this practice. METHODS We performed a multicenter retrospective study at 4 academic lung transplant centers to determine the association of gastroesophageal reflux disease and fundoplication with bronchiolitis obliterans syndrome and survival using Cox multivariable regression. RESULTS Of 542 patients, 136 (25.1%) underwent fundoplication; 99 (18%) were found to have reflux disease without undergoing fundoplication. Blanking the first year after transplantation, fundoplication was not associated with a benefit regarding freedom from bronchiolitis obliterans syndrome (hazard ratio [HR], 0.93; 95% CI, 0.58-1.49) or death (HR, 0.97; 95% CI, 0.47-1.99) compared with reflux disease without fundoplication. However, a time-dependent adjusted analysis found a slight decrease in mortality (HR, 0.59; 95% CI, 0.28-1.23; P = .157), bronchiolitis obliterans syndrome (HR, 0.68; 95% CI, 0.42-1.11; P = .126), and combined bronchiolitis obliterans syndrome or death (HR, 0.66; 95% CI, 0.42-1.04; P = .073) in the fundoplication group compared with the gastroesophageal reflux disease group. CONCLUSIONS Although a statistically significant benefit from fundoplication was not determined because of limited sample size, follow-up, and potential for selection bias, a randomized, prospective study is still warranted.
Collapse
Affiliation(s)
- Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
| | - Brian C Gulack
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Kenneth McCurry
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Marie M Budev
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Tammy L Reece
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Anne O Lidor
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Scott M Palmer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - R Duane Davis
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
13
|
Gao Q, DeLaura I, Hartwig MG. Commentary: Rethinking the Role of Gastroesophageal Reflux in Lung Transplant Candidates. Semin Thorac Cardiovasc Surg 2023; 35:187-188. [PMID: 35278663 DOI: 10.1053/j.semtcvs.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Qimeng Gao
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Isabel DeLaura
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
14
|
Routine Reflux Testing Guides Timely Antireflux Treatment to Reduce Acute and Chronic Rejection After Lung Transplantation. Clin Transl Gastroenterol 2022; 14:e00538. [PMID: 36201668 PMCID: PMC9875950 DOI: 10.14309/ctg.0000000000000538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/23/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Gastroesophageal reflux has been associated with poorer lung transplantation outcomes, although no standard approach to evaluation/management has been adopted. We aimed to evaluate the effect of timely antireflux treatment as guided by routine reflux testing on postlung transplant rejection outcomes. METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary center. All patients underwent pretransplant ambulatory pH monitoring. Timely antireflux treatment was defined as proton pump inhibitor initiation or antireflux surgery within 6 months of transplantation. Patients were separated into 3 groups: normal pH monitoring (-pH), increased reflux (+pH) with timely treatment, and +pH with delayed treatment. Rejection outcomes included acute rejection, bronchiolitis obliterans syndrome, and chronic lung allograft dysfunction per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses using Cox proportional hazard models were applied. Patients not meeting outcomes were censored at death or last clinic visit. RESULTS One hundred seventy-five patients (59% men/mean 56.3 yr/follow-up: 496 person-years) were included. On multivariable analyses, +pH/delayed treatment patients had higher risks of acute rejection (adjust hazard ratio [aHR]:3.81 [95% confidence interval [CI]: 1.90-7.64], P = 0.0002), bronchiolitis obliterans syndrome (aHR: 2.22 [95% CI: 1.07-4.58], P = 0.03), and chronic lung allograft dysfunction (aHR: 2.97 [95% CI: 1.40-6.32], P = 0.005) than +pH/timely treatment patients. Similarly, rejection risks were increased among +pH/delayed treatment patients vs -pH patients (all P < 0.05). No significant differences in rejection risks were noted between +pH/timely treatment patients and -pH patients. Failure/complications of antireflux treatment were rare and similar among groups. DISCUSSION Timely antireflux treatment, as directed by pretransplant reflux testing, was associated with reduced allograft rejection risks and demonstrated noninferiority to patients without reflux. A standardized peri-transplant test-and-treat algorithm may guide timely reflux management to improve lung transplant outcomes.
Collapse
|
15
|
Chetwood JD, Volovets A, Sivam S, Koh C. Surgical considerations in cystic fibrosis: what every general surgeon needs to know. ANZ J Surg 2022; 92:2425-2432. [PMID: 35920692 PMCID: PMC9804981 DOI: 10.1111/ans.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/12/2022] [Indexed: 01/09/2023]
Abstract
Cystic fibrosis (CF) is a complex multiorgan disease, which often affects the gastrointestinal tract. With improved CF specific therapies and multidisciplinary management, patients with CF are now living longer with a median life expectancy of around 50 years. This increased life expectancy has resulted in corresponding increase in presentations of the CF patient with comorbid surgical conditions that were never important considerations. Investigations and management of these conditions, such as distal intestinal obstruction syndrome and colorectal cancer warrant good clinical understanding of the unique challenges that CF patients present including chronic immunosuppression, impaired respiratory function and their multi-organ dysfunction. The purpose of this review is to provide general surgeons with a contemporary update on the CF related surgical issues as they are likely to become increasingly involved in the care of these complex patients and form an integral part of the multidisciplinary team.
Collapse
Affiliation(s)
- John D. Chetwood
- AW Morrow Gastroenterology and Liver CentreRoyal Prince Alfred HospitalSydneyNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Anastasia Volovets
- AW Morrow Gastroenterology and Liver CentreRoyal Prince Alfred HospitalSydneyNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Sheila Sivam
- Department of Respiratory and Sleep MedicineRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe)Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| |
Collapse
|
16
|
Blackett JW, Benvenuto L, Leiva-Juarez MM, D'Ovidio F, Arcasoy S, Jodorkovsky D. Risk Factors and Outcomes for Gastroparesis After Lung Transplantation. Dig Dis Sci 2022; 67:2385-2394. [PMID: 34524597 DOI: 10.1007/s10620-021-07249-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroparesis is common after lung transplantation and is associated with worse transplant outcomes, including the development of chronic lung allograft dysfunction (CLAD). This study sought to identify the prevalence, risk factors, and outcomes associated with a new diagnosis of gastroparesis after lung transplantation. METHODS This was a single-center retrospective study of patients who underwent lung transplantation in 2008-2018. The primary outcome was a new diagnosis of gastroparesis within 3 years of transplant. Secondary outcomes included a new diagnosis of gastroesophageal reflux and the association between gastroparesis and both post-transplant survival and CLAD-free survival. Multivariable logistic regression was used to compare diagnosis of gastroparesis and gastroesophageal reflux, while multivariable Cox proportional hazards models were used to analyze gastroparesis and post-transplant outcomes. RESULTS Of 616 patients with no prior history of gastroparesis, 107 (17.4%) were diagnosed with delayed gastric emptying within 3 years of transplant. On multivariable logistic regression, black race (OR 2.16, 95% CI 1.18-3.98, p = 0.013) was significantly associated with a new diagnosis of gastroparesis. Age, sex, history of diabetes, connective tissue disease, type of transplant, diagnosis group, renal function, and body mass index were not predictive of gastroparesis post-transplant. Gastroparesis was significantly associated with CLAD (HR 1.76, 95% CI 1.20-2.59, p = 0.004), but not with overall mortality (HR 1.16, p = 0.43). CONCLUSION While gastroparesis is common after lung transplantation, it remains difficult to predict which patients will develop these complications post-transplant. Black patients were more likely to be diagnosed with gastroparesis after adjusting for relevant confounders. Gastroparesis is associated with increased risk of CLAD, and further studies are needed to assess whether early detection and treatment can reduce the incidence of CLAD.
Collapse
Affiliation(s)
- John W Blackett
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, 622 West 168th Street, New York, NY, USA.
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Miguel M Leiva-Juarez
- Division of Cardiac, Vascular, and Thoracic Surgery, Department of Surgery, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Frank D'Ovidio
- Division of Cardiac, Vascular, and Thoracic Surgery, Department of Surgery, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Selim Arcasoy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, 622 West 168th Street, New York, NY, USA
| |
Collapse
|
17
|
Razia D, Mittal SK, Bansal S, Ravichandran R, Smith MA, Walia R, Bremner RM, Mohanakumar T, Tokman S. Lung Transplant Candidates With Pretransplant Gastroesophageal Reflux and Antibodies to Lung Self-antigens Have Shorter CLAD-free Survival After Transplant. Transplant Direct 2022; 8:e1294. [PMID: 35187218 PMCID: PMC8845115 DOI: 10.1097/txd.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/03/2022] Open
Abstract
Pre–lung transplant (LTx) gastroesophageal reflux (GER) and circulating antibodies against the lung self-antigens (SAbs) collagen V and K-alpha-1 tubulin may predispose recipients to chronic lung allograft dysfunction (CLAD). We aimed to study the association of pre-LTx GER or pre-LTx SAbs with CLAD.
Collapse
|
18
|
Derousseau T, Chan WW, Cangemi D, Kaza V, Lo WK, Gavini S. Delayed Gastric Emptying in Prelung Transplant Patients Is Associated With Posttransplant Acute Cellular Rejection Independent of Reflux. J Clin Gastroenterol 2022; 56:e121-e125. [PMID: 33780225 DOI: 10.1097/mcg.0000000000001502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/24/2020] [Indexed: 12/10/2022]
Abstract
GOAL The goal of this study was to evaluate the relationship between pretransplant delayed gastric emptying (DGE) and posttransplant acute cellular rejection (ACR) in lung transplant recipients. BACKGROUND DGE is very prevalent (23% to 91%) after lung transplantation but pretransplant prevalence has not been well studied. DGE may lead to poor posttransplant outcomes by predisposing to microaspiration. Pretransplant testing for DGE may help identify patients at risk for negative posttransplant outcomes including ACR. MATERIALS AND METHODS A retrospective review of a prospectively collected database of consecutive patients undergoing prelung transplant evaluation at a tertiary referral center from 2010 to 2015 was performed. Patients with pretransplant gastric emptying scintigraphy were included in the study. ACR diagnosis was made using International Society for Heart and Lung Transplantation (ISHLT) histologic criteria. Typical gastroparesis symptoms at the time of gastric emptying scintigraphy and pretransplant 24-hour pH impedance monitoring (MII-pH) data was collected. Logistic regression was used for multivariate analysis. Subgroup analyses were performed to account for gastroesophageal reflux (GER). RESULTS A total of 83 subjects (18 with DGE, 51.8% male, mean age: 53.6 y) met the criteria for inclusion. Patients with DGE were more likely to have typical symptoms of gastroparesis, though 61.1% of DGE patients were asymptomatic. ACR was more prevalent in patients with DGE (33.3% vs. 12.3%, P=0.04). This correlation was independent of GER as measured by MII-pH on subgroup analysis (75% vs. 14.3%, n=0.02). DISCUSSION Lung transplant recipients with pretransplant DGE have a higher incidence of ACR, independent of GER. Routine pretransplant testing for DGE may help identify patients at greater risk for adverse posttransplant outcomes as the majority of patients with DGE are asymptomatic.
Collapse
Affiliation(s)
| | - Walter W Chan
- Department of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David Cangemi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | - Vaidehi Kaza
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Wai-Kit Lo
- Department of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | |
Collapse
|
19
|
Bedair B, Hachem RR. Management of chronic rejection after lung transplantation. J Thorac Dis 2022; 13:6645-6653. [PMID: 34992842 PMCID: PMC8662511 DOI: 10.21037/jtd-2021-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/20/2021] [Indexed: 12/17/2022]
Abstract
Outcomes after lung transplantation are limited by chronic lung allograft dysfunction (CLAD). The incidence of CLAD is high, and its clinical course tends to be progressive over time, culminating in graft failure and death. Indeed, CLAD is the leading cause of death beyond the first year after lung transplantation. Therapy for CLAD has been limited by a lack of high-quality studies to guide management. In this review, we will discuss the diagnosis of CLAD in light of the recent changes to definitions and will discuss the current clinical evidence available for treatment. Recently, the diagnosis of CLAD has been subdivided into bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). The current evidence for treatment of CLAD mainly revolves around treatment of BOS with more limited data existing for RAS. The best supported treatment to date for CLAD is the macrolide antibiotic azithromycin which has been associated with a small improvement in lung function in a minority of patients. Other therapies that have more limited data include switching immunosuppression from cyclosporine to tacrolimus, fundoplication for gastroesophageal reflux, montelukast, extracorporeal photopheresis (ECP), aerosolized cyclosporine, cytolytic anti-lymphocyte therapies, total lymphoid irradiation (TLI) and the antifibrotic agent pirfenidone. Most of these treatments are supported by case series and observational studies. Finally, we will discuss the role of retransplantation for CLAD.
Collapse
Affiliation(s)
- Bahaa Bedair
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, MO 63110, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, MO 63110, USA
| |
Collapse
|
20
|
Abstract
The aim of this review is to explore the relationship between esophageal syndromes and pulmonary diseases considering the most recent data available. Prior studies have shown a close relationship between lung diseases such as asthma, chronic obstructive pulmonary disorders (COPD), Idiopathic pulmonary fibrosis (IPF), and lung transplant rejection and esophageal dysfunction. Although the association has long been demonstrated, the exact relationship remains unclear. Clinical experience has shown a bidirectional relationship where esophageal disease may influence the outcomes of pulmonary disease and vice versa. The impact of esophageal dysfunction on pulmonary disorders may also be related to 2 different mechanisms: the reflux pathway leading to microaspiration and the reflex pathway triggering vagally mediated airway reactions. The aim of this review is to further explore these relationships and pathophysiologic mechanisms. Specifically, we discuss the proposed hypotheses for the relationship between the 2 diseases, as well as the pathophysiology and new developments in clinical management.
Collapse
|
21
|
Black RJ, Novakovic D, Plit M, Miles A, MacDonald P, Madill C. Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis. J Heart Lung Transplant 2021; 40:1483-1494. [PMID: 34836605 DOI: 10.1016/j.healun.2021.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/29/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022] Open
Abstract
Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life.
Collapse
Affiliation(s)
- Rebecca J Black
- Speech Pathology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Australia.
| | - Daniel Novakovic
- Faculty of Medicine and Health, The University of Sydney, Australia
| | | | | | - Peter MacDonald
- Faculty of Medicine and Health, The University of Sydney, Australia
| | - Catherine Madill
- Faculty of Medicine and Health, The University of Sydney, Australia
| |
Collapse
|
22
|
Chronic lung allograft dysfunction. Indian J Thorac Cardiovasc Surg 2021; 38:318-325. [DOI: 10.1007/s12055-021-01228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/11/2021] [Accepted: 06/21/2021] [Indexed: 10/19/2022] Open
|
23
|
Abstract
PURPOSE OF REVIEW To explore the role of upper gastrointestinal disease in the clinical course of lung transplant patients - including its pathophysiology, diagnostic testing, and treatment options. RECENT FINDINGS Gastroesophageal reflux disease (GERD) and foregut motility disorders are more prevalent among end-stage lung disease patients and are associated with poorer outcomes in lung transplant recipients. A proposed mechanism is the exposure of the lung allograft to aspirated contents, resulting in inflammation and rejection. Diagnostic tools to assess for these disorders include multichannel intraluminal impedance and pH (MII-pH) testing, high resolution esophageal manometry (HREM), and gastric emptying scintigraphy. The main treatment options are medical management with acid suppressants and/or prokinetic agents and anti-reflux surgery. In particular, data support the use of early anti-reflux surgery to improve outcomes. Newer diagnostic tools such as MII-pH testing and HREM allow for the identification of both acid and non-acid reflux and esophageal motility disorders, respectively. Recent studies have demonstrated that early anti-reflux surgery within six months post-transplant better protects against allograft injury and pulmonary function decline when compared to late surgery. However, further prospective research is needed to evaluate the short and long-term outcomes of these diagnostic approaches and interventions.
Collapse
|
24
|
Leiva-Juárez MM, Urso A, Costa J, Stanifer BP, Sonett JR, Benvenuto L, Aversa M, Robbins H, Shah L, Arcasoy S, D’Ovidio F. Fundoplication after lung transplantation in patients with systemic sclerosis-related end-stage lung disease. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:247-255. [PMID: 35387211 PMCID: PMC8922666 DOI: 10.1177/23971983211016210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/19/2021] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Gastroesophageal reflux and aspiration are risk factors for chronic lung allograft dysfunction in lung transplant recipients. Patients with systemic sclerosis are at an increased risk of aspiration due to esophageal dysmotility and an ineffective lower esophageal sphincter. The aim of this study is to understand the effect of fundoplication on outcomes in systemic sclerosis recipients. METHODS Between 2001 and 2019, 168 systemic sclerosis patients were referred for lung transplantation-51 (30.3%) were listed and 36 (21.4%) were transplanted. Recipients were stratified whether they underwent a fundoplication (n = 10, 27.8%) or not (n = 26, 72.2%). Freedom from chronic lung allograft dysfunction and survival were analyzed using log-rank test. Multivariable analysis for known risk factors was performed using a Cox-proportional hazards model. RESULTS Median time to fundoplication after transplantation was 16.4 months (interquartile range: 9.6-25.1) and all were laparoscopic (Dor 50%, Nissen 40%, Toupet 10%). There were no differences in acute rejection ⩾ A1 (26.9% vs 30%), or primary graft dysfunction grades 2-3 at 72 h (42.3% vs 40%) between groups. Recipients with fundoplication had an increased freedom from chronic lung allograft dysfunction (p = 0.035) and overall survival (p = 0.01). Fundoplication was associated with a reduced risk of mortality adjusting for other comorbidities (hazard ratio = 0.13; 95% confidence interval = 0.02-0.65; p = 0.014). Double and single lung transplant did not have different post-transplant survival. CONCLUSION Fundoplication in systemic sclerosis lung transplant recipients is associated with greater freedom from chronic lung allograft dysfunction and overall survival. Screening for reflux and aspiration followed by early fundoplication may delay graft deterioration in this population.
Collapse
Affiliation(s)
- Miguel M Leiva-Juárez
- Department of Surgery, Section of
General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY,
USA
| | - Andreacarola Urso
- Department of Surgery, Section of
General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY,
USA
| | - Joseph Costa
- Department of Surgery, Section of
General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY,
USA
| | - Bryan P Stanifer
- Department of Surgery, Section of
General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY,
USA
| | - Joshua R Sonett
- Department of Surgery, Section of
General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY,
USA
| | - Luke Benvenuto
- Department of Pulmonary, Allergy and
Critical Care Medicine, Columbia University Irving Medical Center, New York, NY,
USA
| | - Megan Aversa
- Department of Pulmonary, Allergy and
Critical Care Medicine, Columbia University Irving Medical Center, New York, NY,
USA
| | - Hilary Robbins
- Department of Pulmonary, Allergy and
Critical Care Medicine, Columbia University Irving Medical Center, New York, NY,
USA
| | - Lori Shah
- Department of Pulmonary, Allergy and
Critical Care Medicine, Columbia University Irving Medical Center, New York, NY,
USA
| | - Selim Arcasoy
- Department of Pulmonary, Allergy and
Critical Care Medicine, Columbia University Irving Medical Center, New York, NY,
USA
| | - Frank D’Ovidio
- Department of Surgery, Section of
General Thoracic Surgery, Columbia University Irving Medical Center, New York, NY,
USA
| |
Collapse
|
25
|
Kapnadak SG, Raghu G. Lung transplantation for interstitial lung disease. Eur Respir Rev 2021; 30:30/161/210017. [PMID: 34348979 DOI: 10.1183/16000617.0017-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/02/2021] [Indexed: 01/18/2023] Open
Abstract
Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.
Collapse
Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA .,Dept of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| |
Collapse
|
26
|
Kawano-Dourado L, Lee JS. Management of Connective Tissue Disease-Associated Interstitial Lung Disease. Clin Chest Med 2021; 42:295-310. [PMID: 34024405 DOI: 10.1016/j.ccm.2021.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The presence of interstitial lung disease (ILD) negatively affects prognosis among patients with an underlying connective tissue disease (CTD). The initial approach to care should determine whether the CTD-ILD needs pharmacologic treatment or not. There is little direct evidence to guide who and how to treat. At present, any severe, active, and/or progressive ILD should be pharmacologically treated. Immunosuppressants and/or corticosteroids are the mainstay of pharmacologic therapy for all CTD-ILDs, whereas antifibrotics may be beneficial in some scenarios. A comprehensive and multidisciplinary approach to management is also an important aspect of patient care.
Collapse
Affiliation(s)
- Leticia Kawano-Dourado
- HCor Research Institute, Hospital do Coracao, Rua Abilio Soares, 250, 12º andar, Sao Paulo, Sao Paulo 04005-909, Brazil; Pulmonary Division, Heart Institute (InCor), Medical School, University of Sao Paulo, Sao Paulo, Brazil; INSERM UMR 1152, University of Paris, Paris, France.
| | - Joyce S Lee
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, C-323, Academic Office 1, Room 7223, Aurora, CO 80045, USA
| |
Collapse
|
27
|
Leiva-Juarez MM, Benvenuto L, Costa J, Blackett JW, Aversa M, Robbins H, Shah L, Stanifer BP, Lemaître PH, Jodorkovsky D, Arcasoy S, Sonett JR, D'Ovidio F. Identification of Lung Transplant Recipients with a Survival Benefit after Fundoplication. Ann Thorac Surg 2021; 113:1801-1810. [PMID: 34280376 DOI: 10.1016/j.athoracsur.2021.05.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/02/2021] [Accepted: 05/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) and aspiration of enteric contents is associated with worse outcomes after lung transplant. The purpose of this study is to elucidate populations that benefit the most from fundoplication after lung transplant. METHODS Lung transplants from 2001-2019 (n=971) were retrospectively reviewed and stratified by a fundoplication before (n=128) or after (n=24) chronic lung allograft dysfunction (CLAD) development vs those who didn't. Patients with a fundoplication prior to CLAD were propensity-matched to those without a fundoplication. The primary outcome of interest was post-transplant survival. Time-to-event rates were calculated using a multivariable Cox proportional hazards model and Kaplan-Meier functions. RESULTS A fundoplication prior to CLAD improved post-transplant survival before and after propensity-matching, and remained a significant predictor after adjusting for baseline characteristics (HR:0.57, 95% CI:0.4-0.8, P=0.001). Recipients with a restrictive disorder (HR: 0.46, 95% CI:0.3-0.73, P=0.001), age <65 (HR:0.48, 95% CI:0.32-0.71, P<0.001), and both single (HR:0.47, 95% CI:0.28-0.79, P=0.005) or double (HR:0.55, 95% CI:0.32-0.93, P=0.027) lung transplants had a significant decrease in mortality after fundoplication. The effect was present after excluding early deaths and/or CLAD diagnoses. GERD diagnosed by pH, impedance or EGD was not associated with worse outcomes. Among patients with CLAD, a fundoplication was an independent predictor of post-CLAD survival (HR:0.27, 95% CI:0.12-0.61, P=0.002). CONCLUSIONS A fundoplication before or after CLAD development is an independent predictor of survival. Younger patients with restrictive disease, independent of the type of transplant, have a survival benefit. GERD diagnosed by conventional methods was not associated with worse survival.
Collapse
Affiliation(s)
- Miguel M Leiva-Juarez
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joseph Costa
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - John W Blackett
- Division of Gastroenterology, Columbia University Medical Center, New York, New York
| | - Meghan Aversa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Hilary Robbins
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Lori Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Bryan P Stanifer
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Phillippe H Lemaître
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Daniela Jodorkovsky
- Division of Gastroenterology, Columbia University Medical Center, New York, New York
| | - Selim Arcasoy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joshua R Sonett
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Frank D'Ovidio
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York.
| |
Collapse
|
28
|
Henen S, Denton C, Teckman J, Borowitz D, Patel D. Review of Gastrointestinal Motility in Cystic Fibrosis. J Cyst Fibros 2021; 20:578-585. [PMID: 34147362 DOI: 10.1016/j.jcf.2021.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Gastrointestinal manifestations in patients with cystic fibrosis (CF) are extremely common and have recently become a research focus. Gastrointestinal (GI) dysfunction is poorly understood in the CF population, despite many speculations including the role of luminal pH, bacterial overgrowth, and abnormal microbiome. Nevertheless, dysmotility is emerging as a possible key player in CF intestinal symptoms. Our review article aims to explore the sequelae of defective cystic fibrosis transmembrane conductance regulator (CFTR) genes on the GI tract as studied in both animals and humans, describe various presentations of intestinal dysmotility in CF, review newer diagnostic motility techniques including intraluminal manometry, and review the current literature regarding the potential role of dysmotility in CF-related intestinal pathologies.
Collapse
Affiliation(s)
- Sara Henen
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104.
| | - Christine Denton
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104
| | - Jeff Teckman
- Interim Chair, Department of Pediatrics, Professor of Pediatrics and Biochemistry, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand BLVD, St. Louis, MO 63104.
| | - Drucy Borowitz
- Emeritus Professor of Clinical Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY, 1001 Main Street, Buffalo, NY, 14203.
| | - Dhiren Patel
- Associate Professor and Medical Director, Neurogastroenterology and Motility Program, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104.
| |
Collapse
|
29
|
Urso A, Leiva-Juárez MM, Briganti DF, Aramini B, Benvenuto L, Costa J, Nandakumar R, Gomez EA, Robbins HY, Shah L, Aversa M, Sonnet JR, Arcasoy S, Cremers S, D'Ovidio F. Aspiration of conjugated bile acids predicts adverse lung transplant outcomes and correlates with airway lipid and cytokine dysregulation. J Heart Lung Transplant 2021; 40:998-1008. [PMID: 34183226 DOI: 10.1016/j.healun.2021.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/08/2021] [Accepted: 05/20/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Duodeno-gastroesophageal reflux aspiration is associated with chronic lung allograft dysfunction (CLAD). Reflux aspirate can contain bile acids (BA), functional molecules in the gastro-intestinal tract with emulsifying properties. We sought to determine and quantify the various BA species in airways of the lung transplant recipients to better understand the various effects of aspirated BA that contribute to post-transplantation outcomes. METHODS Bronchial washings (BW) were prospectively collected from lung transplant recipients and subsequently assayed by liquid chromatography-mass spectrometry for 13 BA and 25 lipid families. Patients were monitored for CLAD, rejection, inflammation and airway infections. RESULTS Detectable BA were present in 45/50 patients (90%) at 3 months after transplant. Elevated BA and predominance of conjugated species were independent predictors of CLAD (hazard ratio 7.9; 95% confidence interval 2.7-23.6; p < 0.001 and 7.3; 2.4-22; p < 0.001, respectively) and mortality (hazard ratio 4.4; 1.5-12.7; p = 0.007 and 4.8; 1.4-15.8; p = 0.01, respectively). High BA associated with increased positive bacterial cultures (60% vs 25%, p = 0.02). Primary conjugated species independently correlated with the rate of bacterial cultures during the first-year post-transplant (Beta coefficient: 0.77; 0.28-1.26; p = 0.003) and changes in airway lipidome and cytokines. CONCLUSIONS Higher BA levels and predominance of conjugated BA are independent predictors of chronic lung allograft dysfunction, mortality and bacterial infections. Primary conjugated BA are related to distinct changes in airway lipidome and inflammatory cytokines. This elucidates novel evidence into the mechanism following BA aspiration and proposes novel markers for prediction of adverse post-transplant outcomes.
Collapse
Affiliation(s)
- Andreacarola Urso
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Miguel M Leiva-Juárez
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Domenica F Briganti
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Beatrice Aramini
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Luke Benvenuto
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Joseph Costa
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Renu Nandakumar
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Estela Area Gomez
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Hilary Y Robbins
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Lori Shah
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Meghan Aversa
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Joshua R Sonnet
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Selim Arcasoy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Serge Cremers
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Frank D'Ovidio
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY.
| |
Collapse
|
30
|
Esophageal dysmotility and lung disease in patients with systemic sclerosis: is there a possible association or correlation? A retrospective chart review. Rheumatol Int 2021; 41:1965-1970. [PMID: 34032895 DOI: 10.1007/s00296-021-04880-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Our aim was to evaluate the relationship between esophageal dysmotility and lung disease by correlating the results of Echocardiogram and Pulmonary Function Test (PFT) with Esophageal Transit Study (ETT). METHODS Charts of Systemic Sclerosis (SSc) patients fulfilling 2013 ACR/EULAR classification criteria seen in Rheumatology clinics were reviewed and their demographics, ETT result, PFT, and echocardiogram data were collected at baseline, years 1, 3, 5, and 10. Patients were divided based on their ETT status and were compared with respect to each variable using a two-sided two-sample t test for continuous variables and a Fisher's exact test for categorical variables. RESULTS 130 patients were identified with either limited cutaneous SSc (109) or diffuse cutaneous SSc (21) with a mean age of 52.65 years. The mean DLCO was statistically worse in abnormal ETT patients [p value = 0.0004] as were the progression rates per year for DLCO at - 2.25 (p value = 0.019). Progression rate of FVC per year was statistically significant in the abnormal ETT group, although the mean value was not. The number of patients with abnormal PASP was not statistically different between the two groups (p values 0.104, 0.178, 0.653 at baseline, years 3 and 5, respectively). CONCLUSION The presence of esophageal dysmotility was associated with increased pulmonary involvement in the form of abnormal DLCO with worsening progression rates per year. There was no statistically significant difference in PASP and FVC between the two groups; however, the progression rate for FVC was worse in adjusted models.
Collapse
|
31
|
Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
Collapse
Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| |
Collapse
|
32
|
Esophageal Motility Disorders Associated With Death or Allograft Dysfunction After Lung Transplantation? Results of a Retrospective Monocentric Study. Clin Transl Gastroenterol 2021; 11:e00137. [PMID: 32352712 PMCID: PMC7145052 DOI: 10.14309/ctg.0000000000000137] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Pathological gastroesophageal reflux (GER) is a known risk factor for bronchiolitis obliterans syndrome (BOS) after lung transplantation. This study aimed at determining whether functional esophageal evaluation might predict BOS occurrence and survival in this setting. METHODS Ninety-three patients who underwent esophageal high-resolution manometry and 24-hour pH-impedance monitoring within the first year after lung transplantation were retrospectively included. A univariable analysis was performed to evaluate the parameters associated with GER disease and BOS occurrence. The Cox regression model was used to identify the prognostic factors of death or retransplantation. RESULTS Thirteen percent of patients exhibited major esophageal motility disorders and 20% pathological GER. GER occurrence was associated with younger age, cystic fibrosis, and hypotensive esophagogastric junction. Within a median follow-up of 62 months, 10 patients (11%) developed BOS, and no predictive factors were identified. At the end of the follow-up, 10 patients died and 1 underwent retransplantation. The 5-year cumulative survival rate without retransplantation was lower in patients with major esophageal motility disorders compared with that in those without (75% vs 90%, P = 0.01) and in patients who developed BOS compared with that in those without (66% vs 91%; P = 0.005). However, in multivariable analysis, major esophageal motility disorders and BOS were no longer significant predictors of survival without retransplantation. DISCUSSION Major esophageal motility disorders and BOS were associated with allograft survival in lung transplantation in the univariable analysis. Although the causes of this association remain to be determined, this observation confirms that esophageal motor dysfunction should be evaluated in the context of lung transplantation.
Collapse
|
33
|
J Burton S, Hachem C, Abraham JM. Luminal Gastrointestinal Manifestations of Cystic Fibrosis. Curr Gastroenterol Rep 2021; 23:4. [PMID: 33758994 DOI: 10.1007/s11894-021-00806-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW People with cystic fibrosis (CF) are living longer. General age-related and CF-specific gastrointestinal symptoms are increasingly recognized. In this article, we review the latest data on luminal gastrointestinal manifestations in CF. RECENT FINDINGS People with CF have increased incidence of gastroesophageal reflux disease symptoms and often prescribed proton-pump inhibitors (PPI). PPI use may increase risk of pulmonary exacerbations. Evidence to support gastric fundoplication to improve pulmonary outcomes is limited. Features of intestinal dysmotility are common. There are distinct differences in the gut microbiome in the CF population which may have clinical implications. CF is a possible hereditary digestive cancer syndrome, particularly in regard to colorectal cancer (CRC) with earlier incidence of CRC and advanced colonic neoplasia. Early screening colonoscopy is warranted in the CF population. Gastrointestinal manifestations in CF are prevalent across all digestive organs. More study on the effect of interventions for symptomatic treatment and cancer screening is needed.
Collapse
Affiliation(s)
- Samuel J Burton
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MI, USA
| | - Christine Hachem
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MI, USA
| | - James M Abraham
- Department of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
34
|
Herbella FAM, Patti MG. Gastroesophageal Reflux Disease and Idiopathic Lung Fibrosis. From Heartburn to Lung Transplant, and Beyond. Am Surg 2021; 88:297-302. [PMID: 33629881 DOI: 10.1177/0003134821998686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) and gastroesophageal reflux disease (GERD) are undoubtedly related. Even though it is not clear yet which one is the primary disease, they certainly interact increasing each other's severity. Symptoms are unreliable to diagnose GERD in patients with IPF, and objective evaluation with pH monitoring and/or bronchoalveolar lavage analysis is mandatory. Pharmacological treatment with proton pump inhibitors (PPIs) may bring control of IPF in few patients, but PPIs do not control reflux but just change the pH of the gastric refluxate. Surgical therapy based on a fundoplication is safe and effective as it controls any type of reflux, independently from the pH of the gastric refluxate. In patients waiting for lung transplantation (if they can tolerate a laparoscopic operation under general anesthesia), a fundoplication before the operation might block the progression of IPF, while after transplantation it might prevent rejection by preventing the bronchiolitis obliterans syndrome.
Collapse
Affiliation(s)
| | - Marco G Patti
- Department of Surgery, 58804Escola Paulista de Medicina, São Paulo, Brazil
| |
Collapse
|
35
|
Arjuna A, Olson MT, Walia R, Bremner RM, Smith MA, Mohanakumar T. An update on current treatment strategies for managing bronchiolitis obliterans syndrome after lung transplantation. Expert Rev Respir Med 2020; 15:339-350. [PMID: 33054424 DOI: 10.1080/17476348.2021.1835475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Bronchiolitis obliterans syndrome (BOS), a subtype of chronic lung allograft dysfunction, is quite common, with up to half of all lung recipients developing BOS within 5 years of transplantation. Preventive efforts are aimed at alleviating known risk factors of BOS development, while the primary goal of treatment is to delay the irreversible, fibrotic airway changes, and progressive loss of lung function. AREAS COVERED This narrative review will briefly discuss the updated definition, clinical presentation, pathogenesis, risk factors, and survival after BOS while paying particular attention to the salient evidence for optimal preventive strategies and treatments based on investigations in the modern era. EXPERT OPINION Future translational research focused on further characterizing the complex interplay between immune and nonimmune mechanisms mediating chronic lung rejection is the first step toward mitigating risk of allograft injury, improving early disease detection with noninvasive biomarkers, and ultimately, developing an effective, targeted therapy that can extend the life of the lung allograft.
Collapse
Affiliation(s)
- Ashwini Arjuna
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael T Olson
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA.,Phoenix Campus, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Rajat Walia
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Ross M Bremner
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael A Smith
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | | |
Collapse
|
36
|
van der Mark SC, Hoek RAS, Hellemons ME. Developments in lung transplantation over the past decade. Eur Respir Rev 2020; 29:190132. [PMID: 32699023 PMCID: PMC9489139 DOI: 10.1183/16000617.0132-2019] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
With an improved median survival of 6.2 years, lung transplantation has become an increasingly acceptable treatment option for end-stage lung disease. Besides survival benefit, improvement of quality of life is achieved in the vast majority of patients. Many developments have taken place in the field of lung transplantation over the past decade. Broadened indication criteria and bridging techniques for patients awaiting lung transplantation have led to increased waiting lists and changes in allocation schemes worldwide. Moreover, the use of previously unacceptable donor lungs for lung transplantation has increased, with donations from donors after cardiac death, donors with increasing age and donors with positive smoking status extending the donor pool substantially. Use of ex vivo lung perfusion further increased the number of lungs suitable for lung transplantation. Nonetheless, the use of these previously unacceptable lungs did not have detrimental effects on survival and long-term graft outcomes, and has decreased waiting list mortality. To further improve long-term outcomes, strategies have been proposed to modify chronic lung allograft dysfunction progression and minimise toxic immunosuppressive effects. This review summarises the developments in clinical lung transplantation over the past decade.
Collapse
Affiliation(s)
- Sophie C van der Mark
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
- Authors contributed equally
| | - Rogier A S Hoek
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
- Authors contributed equally
| | - Merel E Hellemons
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
37
|
Malik Z, Shenoy K. Esophageal Evaluation for Patients Undergoing Lung Transplant Evaluation: What Should We Do for Evaluation and Management. Gastroenterol Clin North Am 2020; 49:451-466. [PMID: 32718564 DOI: 10.1016/j.gtc.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Lung transplantation is a high-risk, but lifesaving, procedure for patients with end-stage lung disease. Although 1-year survival is high, long-term survival is not nearly as high, due mainly to acute and chronic rejection. Bronchiolitis obliterans syndrome is the most common type of chronic rejection and often leads to poor outcomes. For this reason, esophageal testing in the lung transplant population has become a major issue, and this article discusses the evidence behind esophageal testing, the importance of esophageal dysmotility gastroesophageal reflux disease, both acidic and nonacidic reflux, and aspiration and the treatment of these findings.
Collapse
Affiliation(s)
- Zubair Malik
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine, Temple University, 3401 North Broad Street, 8th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA.
| | - Kartik Shenoy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, 3401 North Broad Street, 7th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA
| |
Collapse
|
38
|
Davidson JR, Franklin D, Kumar S, Mohammadi B, Dawas K, Eaton S, Curry J, De Coppi P, Abbassi-Ghadi N. Fundoplication to preserve allograft function after lung transplant: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:858-866. [DOI: 10.1016/j.jtcvs.2019.10.185] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/08/2019] [Accepted: 10/25/2019] [Indexed: 12/29/2022]
|
39
|
Chan WW, Ahuja N, Fisichella PM, Gavini S, Rangan V, Vela MF. Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome. Ann N Y Acad Sci 2020; 1482:95-105. [PMID: 32808313 DOI: 10.1111/nyas.14460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/05/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is prevalent and may be associated with both esophageal and extraesophageal syndromes, which include various pulmonary conditions. GERD may lead to pulmonary complications through the "reflux" (aspiration) or "reflex" (refluxate-triggered, vagally mediated airway spasm) mechanisms. While GERD may cause or worsen pulmonary disorders, changes in respiratory mechanics due to lung disease may also increase reflux. Typical esophageal symptoms are frequently absent and objective assessment with reflux monitoring is often needed for diagnosis. Impedance monitoring should be considered in addition to traditional pH study due to the involvement of both acidic and weakly acidic/nonacidic reflux. Antireflux therapy may improve outcomes of some pulmonary complications of GERD, although careful selection of a candidate is paramount to successful outcomes. Further research is needed to identify the optimal testing strategy and patient phenotypes that would benefit from antireflux therapy to improve pulmonary outcomes.
Collapse
Affiliation(s)
- Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nitin Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P Marco Fisichella
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vikram Rangan
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| |
Collapse
|
40
|
Hoffmann-Vold AM, Allanore Y, Bendstrup E, Bruni C, Distler O, Maher TM, Wijsenbeek M, Kreuter M. The need for a holistic approach for SSc-ILD - achievements and ambiguity in a devastating disease. Respir Res 2020; 21:197. [PMID: 32703199 PMCID: PMC7379834 DOI: 10.1186/s12931-020-01459-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/17/2020] [Indexed: 12/13/2022] Open
Abstract
Systemic sclerosis (SSc) is a multi-organ autoimmune disease with complex interactions between immune-mediated inflammatory processes and vascular pathology leading to small vessel obliteration, promoting uncontrolled fibrosis of skin and internal organs. Interstitial lung disease (ILD) is a common but highly variable manifestation of SSc and is associated with high morbidity and mortality. Treatment approaches have focused on immunosuppressive therapies, which have shown some efficacy on lung function. Recently, a large phase 3 trial showed that treatment with nintedanib was associated with a reduction in lung function decline. None of the conducted randomized clinical trials have so far shown convincing efficacy on other outcome measures including quality of life determined by patient reported outcomes. Little evidence is available for non-pharmacological treatment and supportive care specifically for SSc-ILD patients, including pulmonary rehabilitation, supplemental oxygen, symptom relief and adequate information. Improved management of SSc-ILD patients based on a holistic approach is necessary to support patients in maintaining as much quality of life as possible throughout the disease course and to improve long-term outcomes.
Collapse
Affiliation(s)
- Anna-Maria Hoffmann-Vold
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Pb 4950 Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Yannick Allanore
- Rheumatology Department, Cochin Hospital, University of PARIS and INSERM U1016, Paris, France
| | - Elisabeth Bendstrup
- Center for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Toby M Maher
- Inflammation, Repair, and Development Section, National Heart and Lung Institute, Imperial College London, London, UK
- National Institute for Health Research Respiratory Clinical Research Facility, Royal Brompton Hospital, London, UK
- Keck School of Medicine, University of Southern California, 2020 Zonal Avenue, Los Angeles, California, USA
| | - Marlies Wijsenbeek
- Center for Interstitial lung disease and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, Heidelberg University Hospital and German Center for Lung Research, Heidelberg, Germany
| |
Collapse
|
41
|
Le Pavec J, Dauriat G, Gazengel P, Dolidon S, Hanna A, Feuillet S, Pradere P, Crutu A, Florea V, Boulate D, Mitilian D, Fabre D, Mussot S, Mercier O, Fadel E. Lung transplantation for idiopathic pulmonary fibrosis. Presse Med 2020; 49:104026. [PMID: 32437844 DOI: 10.1016/j.lpm.2020.104026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is characterized by relentlessly progressive lung function impairment that is consistently fatal in the absence of lung transplantation, as no curative pharmacological treatment exists. The pace of progression varies across patients, and acute life-threatening exacerbations occur unpredictably, causing further sharp drops in lung function. Recently introduced antifibrotic agents slow the pace of disease progression and may improve survival but fail to stop the fibrotic process. Moreover, the magnitude and kinetics of the response to these drugs cannot be predicted in the individual patient. These characteristics require that lung transplantation be considered early in the course of the disease. However, given the shortage of donor lungs, lung transplantation must be carefully targeted to those patients most likely to benefit. Current guidelines for lung transplantation listing may need reappraisal in the light of recent treatment advances. Patients with IPF often have multiple comorbidities such as coronary heart disease, frailty, and gastro-oesophageal reflux disease (GERD). Consequently, extensive screening for and effective treatment of concomitant conditions is crucial to appropriate candidate selection and outcome optimisation. A multidisciplinary approach is mandatory. Pulmonologists with expertise in IPF must work closely with lung transplant teams. Careful consideration must be given to preoperative optimisation, surgical technique, and pulmonary rehabilitation to produce the best post-transplantation outcomes.
Collapse
Affiliation(s)
- Jérôme Le Pavec
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France.
| | - Gaëlle Dauriat
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Pierre Gazengel
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Samuel Dolidon
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Amir Hanna
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Séverine Feuillet
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Pauline Pradere
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Adrian Crutu
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Valentina Florea
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - David Boulate
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Delphine Mitilian
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Dominique Fabre
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Sacha Mussot
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olaf Mercier
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Elie Fadel
- Service de chirurgie thoracique, vasculaire et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France; Faculté de médecine, université Paris-Sud, université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Inserm, université Paris-Sud, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| |
Collapse
|
42
|
Zhang CYK, Ahmed M, Huszti E, Levy L, Hunter SE, Boonstra KM, Moshkelgosha S, Sage AT, Azad S, Zamel R, Ghany R, Yeung JC, Crespin OM, Frankel C, Budev M, Shah P, Reynolds JM, Snyder LD, Belperio JA, Singer LG, Weigt SS, Todd JL, Palmer SM, Keshavjee S, Martinu T. Bronchoalveolar bile acid and inflammatory markers to identify high-risk lung transplant recipients with reflux and microaspiration. J Heart Lung Transplant 2020; 39:934-944. [PMID: 32487471 DOI: 10.1016/j.healun.2020.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a risk factor for chronic lung allograft dysfunction. Bile acids-putative markers of gastric microaspiration-and inflammatory proteins in the bronchoalveolar lavage (BAL) have been associated with chronic lung allograft dysfunction, but their relationship with GERD remains unclear. Although GERD is thought to drive chronic microaspiration, the selection of patients for anti-reflux surgery lacks precision. This multicenter study aimed to test the association of BAL bile acids with GERD, lung inflammation, allograft function, and anti-reflux surgery. METHODS We analyzed BAL obtained during the first post-transplant year from a retrospective cohort of patients with and without GERD, as well as BAL obtained before and after Nissen fundoplication anti-reflux surgery from a separate cohort. Levels of taurocholic acid (TCA), glycocholic acid, and cholic acid were measured using mass spectrometry. Protein markers of inflammation and injury were measured using multiplex assay and enzyme-linked immunosorbent assay. RESULTS At 3 months after transplantation, TCA, IL-1β, IL-12p70, and CCL5 were higher in the BAL of patients with GERD than in that of no-GERD controls. Elevated TCA and glycocholic acid were associated with concurrent acute lung allograft dysfunction and inflammatory proteins. The BAL obtained after anti-reflux surgery contained reduced TCA and inflammatory proteins compared with that obtained before anti-reflux surgery. CONCLUSIONS Targeted monitoring of TCA and selected inflammatory proteins may be useful in lung transplant recipients with suspected reflux and microaspiration to support diagnosis and guide therapy. Patients with elevated biomarker levels may benefit most from anti-reflux surgery to reduce microaspiration and allograft inflammation.
Collapse
Affiliation(s)
- Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sarah E Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kristen M Boonstra
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sassan Azad
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ricardo Zamel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Oscar M Crespin
- Division of General Surgery, University Health Network, University of Toronto, Toronto, Canada
| | | | | | - Pali Shah
- Johns Hopkins University Hospital, Baltimore, Maryland
| | | | | | | | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Jamie L Todd
- Duke University Medical Center, Durham, North Carolina
| | | | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
| | | |
Collapse
|
43
|
Griffiths TL, Nassar M, Soubani AO. Pulmonary manifestations of gastroesophageal reflux disease. Expert Rev Respir Med 2020; 14:767-775. [PMID: 32308062 DOI: 10.1080/17476348.2020.1758068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is a widespread condition with a significant impact on the quality of life and healthcare resources. In addition to its gastrointestinal problems, GERD has been linked to a variety of respiratory diseases either as a direct cause, or as a risk factor to the inability to control or worsening of the disease. AREAS COVERED We performed a literature search in the PubMed database for articles addressing GERD and pulmonary diseases. This review will discuss several different pulmonary diseases affected by GERD ranging from upper airway including chronic cough, vocal cord dysfunction, lower airway diseases including COPD, asthma, and bronchiolitis obliterans syndrome to parenchymal diseases such as interstitial lung diseases. The review will discuss several different pulmonary manifestations of GERD and their contribution to patient mortality and morbidity. It will also review the mechanisms leading to these diseases, diagnostic workup, and the role of the available treatment options. EXPERT OPINION GERD is often overlooked as a cause of respiratory symptoms and illnesses. The literature is sparse on the relation between GERD and respiratory diseases such as interstitial lung diseases and bronchiolitis obliterans including its role in pathogenesis, mechanisms of lung injury, and whether treatment of GERD is effective in managing such illnesses.
Collapse
Affiliation(s)
- Tricia L Griffiths
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine , Detroit, MI, USA
| | - Mo'ath Nassar
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine , Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine , Detroit, MI, USA
| |
Collapse
|
44
|
Abstract
Introduction: Lung transplantation remains an important treatment for patients with end stage lung disease. Chronic lung allograft dysfunction (CLAD) remains the greatest limiting factor for long term survival. As the diagnosis of CLAD is based on pulmonary function tests, significant lung injury is required before a diagnosis is feasible, likely when irreversible damage has already occurred. Therefore, research is ongoing for early CLAD recognition, with biomarkers making up a substantial amount of this research.Areas covered: The purpose of this review is to describe available biomarkers, focusing on those which aid in predicting CLAD and distinguishing between different CLAD phenotypes. We describe biomarkers presenting in bronchial alveolar lavage (BAL) as well as circulating in peripheral blood, both of which offer an appealing alternative to lung biopsy.Expert opinion: Development of CLAD involves complex, multiple immune and nonimmune mechanisms. Therefore, evaluation of potential CLAD biomarkers serves a dual purpose: clinically, the goal remains early detection and identification of patients at increased risk. Simultaneously, biomarkers offer insight into the different mechanisms involved in the pathophysiology of CLAD, leading to the development of possible interventions. The ultimate goal is the development of both preventive and early intervention strategies for CLAD to improve the overall survival of our lung transplant recipients.
Collapse
Affiliation(s)
- Osnat Shtraichman
- Division of Pulmonary, Allergy & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary institute, Rabin Medical Center, Petach Tikva, Israel; Sackler School of Medicine, Tel Aviv, Israel
| | - Joshua M Diamond
- Division of Pulmonary, Allergy & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
45
|
Gualdoni J, Ritzenthaler J, Burlen J, Stocker A, Abell T, Roman J, Nunley DR. Gastroesophageal Reflux and Microaspiration in Lung Transplant Recipients: The Utility of a Single Esophageal Manometry and pH Probe Monitoring Study. Transplant Proc 2020; 52:977-981. [PMID: 32151388 DOI: 10.1016/j.transproceed.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear. METHODS Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX. RESULTS Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively. CONCLUSION Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.
Collapse
Affiliation(s)
- J Gualdoni
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States.
| | - J Ritzenthaler
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Burlen
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - A Stocker
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - T Abell
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Roman
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States; Robley Rex VA Medical Center, Louisville, Kentucky, United States
| | - D R Nunley
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| |
Collapse
|
46
|
Posner S, Finn RT, Shimpi RA, Wood RK, Fisher D, Hartwig MG, Klapper J, Reynolds J, Niedzwiecki D, Parish A, Leiman DA. Esophageal contractility increases and gastroesophageal reflux does not worsen after lung transplantation. Dis Esophagus 2019; 32:1-8. [PMID: 31076744 DOI: 10.1093/dote/doz039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 02/28/2019] [Accepted: 04/02/2019] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux and esophageal dysmotility are common in patients with advanced lung disease and are associated with allograft dysfunction after lung transplantation. The effect of transplantation on reflux and esophageal motility is unclear. The aim of this study was to describe the changes in esophageal function occurring after lung transplantation. A retrospective cohort study was performed on lung transplant candidates evaluated at a tertiary care center between 2015 and 2016. A total of 76 patients who underwent lung transplantation had high-resolution manometry and ambulatory pH-metry before and after transplant. Demographic data, esophageal function testing results, and clinical outcomes such as pulmonary function testing were collected and analyzed using appropriate statistical tests and multivariable regression. Of the 76 patients, 59 (78%) received a bilateral transplant. There was a significant increase in esophageal contractility posttransplant, with an increase in median distal contractile integral from 1470 to 2549 mmHg cm s (P < 0.01). There were 19 patients with Jackhammer esophagus posttransplant, including 15 patients with normal motility pretransplant. Nine patients with ineffective or fragmented peristalsis pretransplant had normal manometry posttransplant. Abnormal pH-metry was observed in 35 (46%) patients pretransplant and 29 (38%) patients posttransplant (P = 0.33). Patients with gastroesophageal reflux disease posttransplant had less improvement in pulmonary function at one year, as measured by forced expiratory volume (P = 0.04). These results demonstrate that esophageal contractility increases significantly after lung transplantation, with an associated change in motility classification. In comparison, gastroesophageal reflux does not worsen, but is associated with worse pulmonary function, posttransplant.
Collapse
Affiliation(s)
| | | | | | | | - Deborah Fisher
- Division of Gastroenterology.,Duke Clinical Research Institute
| | | | | | - John Reynolds
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology.,Duke Clinical Research Institute
| |
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight recent data regarding feasibility and outcomes following lung transplantation for patients with systemic sclerosis related pulmonary disease as well as to emphasize areas of uncertainly in need of further study. We include a description of our centre's approach to lung transplant evaluation and posttransplant management in this complex patient population. RECENT FINDINGS Historical data have demonstrated that patients with scleroderma have an increased risk of complications following lung transplantation owing to the multisystem nature of disease, particularly concurrent gastrointestinal, cardiac and renal involvement. Emerging data support the safety of lung transplant in appropriately selected patients with scleroderma-related interstitial lung disease and pulmonary arterial hypertension. SUMMARY Accumulating evidence validates that a diagnosis of scleroderma is not a priori a contraindication to lung transplant. In the carefully selected patient, both short-term and long-term outcomes following lung transplantation are comparable to counterparts with fibrotic lung disease or pulmonary arterial hypertension. However, further prospective study to detail how these patients should be evaluated and managed posttransplant is definitely needed. Cardiac disease is an emerging cause of morbidity and mortality in the scleroderma population and deserves particular attention during the pre and posttransplant period.
Collapse
|
48
|
Woodley FW, Hayes D, Kopp BT, Moore-Clingenpeel M, Machado RS, Nemastil CJ, Jadcherla S, Di Lorenzo C, Kaul A, Mousa H. Gastroesophageal reflux in cystic fibrosis across the age spectrum. Transl Gastroenterol Hepatol 2019; 4:69. [PMID: 31620651 DOI: 10.21037/tgh.2019.08.11] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background Scientific advances have improved longevity in cystic fibrosis (CF) patients and many of these patients can expect to experience age-related gastrointestinal co-morbidities. We aimed to assess the extent to which age might impact gastroesophageal reflux (GER) in patients with CF. Methods Our esophageal pH-multichannel intraluminal impedance monitoring database was searched for tracings belonging to CF patients ≥2 years old without prior fundoplication and not taking anti-reflux medications immediately prior (within 7 days) and during the study. Tracings were retrospectively analyzed; Impedance and pH variables were evaluated with respect to age and pulmonary function. Results Twenty-eight patients were enrolled; 16 children (3.1-17.7 years) and 12 adults (18.2-48.9 years). Among pH probe parameters, correlation analysis showed DeMeester score (P=0.011) and number of acid reflux events lasting >5 minutes (P=0.047) to be significantly correlated with age. Age was not significantly correlated with any of the impedance parameters. Age was negatively correlated with baseline impedance (BI) in the distal esophagus (r=-0.424, P=0.023) and BI was negatively correlated with several pH parameters, including reflux index (r=-0.553, P=0.002), number of total acid reflux events (r=-0.576, P=0.001), number of acid reflux events lasting >5 minutes (r=-0.534, P=0.003), and DeMeester score (r=-0.510, P=0.006). Pulmonary function (percent predicted forced expiratory volume in one minute; ppFEV1) was negatively correlated with age (r=-0.494, P=0.0007). The interaction of age and ppFEV1 and any of the reflux parameters, however, was not significant (P>0.05); the strongest evidence for an interaction was found for the number of acid reflux events reaching the proximal esophagus, but this interaction still did not reach statistical significance (P=0.070). Conclusions In a small cohort, we found evidence that age may be associated with increased acid exposure and that both age and increased acid exposure are associated with reduced BI in the distal esophagus. The negative relationship between pulmonary function and age in our cohort is not related to GER. This pilot study supports the need for esophageal assessment and treatment of GER as standard components of clinical care for an aging CF population.
Collapse
Affiliation(s)
- Frederick W Woodley
- Center for Motility Disorders, Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Benjamin T Kopp
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Sudarshan Jadcherla
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carlo Di Lorenzo
- Center for Motility Disorders, Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hayat Mousa
- Division of Gastroenterology, Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, University of California-San Diego, San Diego, CA, USA
| |
Collapse
|
49
|
Ghisa M, Marinelli C, Savarino V, Savarino E. Idiopathic pulmonary fibrosis and GERD: links and risks. Ther Clin Risk Manag 2019; 15:1081-1093. [PMID: 31564886 PMCID: PMC6733342 DOI: 10.2147/tcrm.s184291] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/11/2019] [Indexed: 01/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) and idiopathic pulmonary fibrosis (IPF) are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. GERD is a frequent comorbidity in IPF patients, as demonstrated using combined multichannel intraluminal impedance-pH, despite being mostly clinically silent. According to that, it has been hypothesized that microaspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. In contrast, it cannot be excluded that IPF may favor GERD by increasing the negative intrathoracic pressure. Therefore, this relationship is uncertain as well as not univocal. Nevertheless, the latest international guidelines recommend the use of proton pump inhibitors (PPIs) in IPF based on several data showing that PPIs can stabilize lung function, reduce disease flares and hospitalizations. On the contrary, recent studies not only question the relevance of these results, but also associate the use of PPIs with an increased risk of lung infections and a negative prognostic outcome. The aim of this review is to analyze the possible links between GERD and IPF and their possible therapeutic implications, trying to translate this scientific evidence into useful information for clinical practice.
Collapse
Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carla Marinelli
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| |
Collapse
|
50
|
Margaritopoulos GA, Kokosi MA, Wells AU. Diagnosing complications and co-morbidities of fibrotic interstitial lung disease. Expert Rev Respir Med 2019; 13:645-658. [PMID: 31215263 DOI: 10.1080/17476348.2019.1632196] [Citation(s) in RCA: 10] [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
Introduction: Interstitial lung diseases (ILDs) represent a heterogeneous group of rare disorders that include more than 200 entities, mostly associated with high mortality. In recent years, the progress regarding the understanding of the pathogenesis of these diseases led to the approval of specific treatments. In ILDs, the presence of comorbidities has a significant impact on the quality of life and the survival of patients and, therefore, their diagnosis and treatment has a pivotal role in management and could improve overall outcome. Areas covered: We discuss key diagnostic issues with regard to the most frequent comorbidities in ILDs. Treatment options are also discussed as the decision to investigate more definitively in order to identify specific comorbidities (including lung cancer, pulmonary hypertension, GE reflux, and obstructive sleep apnoea) is critically dependent upon whether comorbidity-specific treatments are likely to be helpful in individual patients, judged on a case by case basis. Expert opinion: The extent to which clinicians proactively pursue the identification of comorbidities depends on realistic treatment goals in individual patients.
Collapse
Affiliation(s)
| | - Maria A Kokosi
- a Interstitial Lung Disease Unit , Royal Brompton Hospital , London , UK
| | - Athol U Wells
- a Interstitial Lung Disease Unit , Royal Brompton Hospital , London , UK
| |
Collapse
|