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Alghubari A, Cheah R, Z Shah S, Naser ARN, Lee AS, DeVault KR, Houghton LA. The impact of lung transplantation on esophageal motility and inter-relationships with reflux and lung mechanics in patients with restrictive and obstructive respiratory disease. Neurogastroenterol Motil 2024; 36:e14788. [PMID: 38523356 DOI: 10.1111/nmo.14788] [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: 01/04/2024] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND For many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed. METHODS We prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33-75 years; 42 men) who underwent high resolution impedance manometry and 24-h pH-impedance before and after LTx. KEY RESULTS RLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post-LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre-LTx (p < 0.001), reducing only in OLD patients' post-LTx (p = 0.02). Reduced EL post-LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco-abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05). CONCLUSIONS AND INFERENCES RLD patients are more likely to show improvement in esophageal motility than OLD patients post-LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration.
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Affiliation(s)
- Ali Alghubari
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Ramsah Cheah
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Sadia Z Shah
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Abdel-Rahman N Naser
- Department of Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Kenneth R DeVault
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Lesley A Houghton
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Santos J, Hays SR, Golden JA, Calabrese DR, Kolaitis N, Kleinhenz ME, Shah R, Estrada AV, Leard LE, Kukreja J, Singer JP, Greenland JR. Decreased Lymphocytic Bronchitis Severity in the Era of Azithromycin Prophylaxis. Transplant Direct 2023; 9:e1495. [PMID: 37575951 PMCID: PMC10414707 DOI: 10.1097/txd.0000000000001495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/02/2023] [Indexed: 08/15/2023] Open
Abstract
Large-airway lymphocytic inflammation (LB), assessed on endobronchial biopsies, has been associated with acute cellular rejection and chronic lung allograft dysfunction (CLAD). Azithromycin (AZI) prophylaxis has been used to prevent airway inflammation and subsequent CLAD, with inconsistent results. We hypothesized that AZI prophylaxis would be associated with reduced LB, changes in bronchoalveolar lavage (BAL) immune cell populations, and improved CLAD-free survival. Methods We compared frequencies of LB from endobronchial biopsies before (N = 1856) and after (N = 975) protocolized initiation of AZI prophylaxis at our center. LB was classified as none, minimal, mild, or moderate by histopathologic analysis. LB grades were compared using ordinal mixed-model regression. Corresponding automated BAL leukocyte frequencies were compared using mixed-effects modeling. The effect of AZI prophylaxis on CLAD-free survival was assessed by a Cox proportional hazards model adjusted for age, sex, ethnicity, transplant indication, and cytomegalovirus serostatus. Results Biopsies in the pre-AZI era had 2-fold increased odds (95% confidence interval, 1.5-2.7; P < 0.001) of higher LB grades. LB was associated with BAL neutrophilia in both eras. However, there was no difference in risk for CLAD or death between AZI eras (hazard ratio 1.3; 95% confidence interval, 0.7-2.0; P = 0.45). Conclusions Decreased airway inflammation in the era of AZI prophylaxis may represent a direct effect of AZI therapy or reflect other practices or environmental changes. In this cohort, AZI prophylaxis was not associated with improved CLAD-free survival.
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Affiliation(s)
- Jesse Santos
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Steven R. Hays
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Jeffrey A. Golden
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | | | - Nicholas Kolaitis
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Mary Ellen Kleinhenz
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Rupal Shah
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Aida Venado Estrada
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Lorriana E. Leard
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Jasleen Kukreja
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - Jonathan P. Singer
- San Francisco Department of Medicine, University of California, San Francisco, CA
| | - John R. Greenland
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of California, San Francisco, CA
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Ramendra R, Fernández-Castillo JC, Huszti E, Ghany R, Aversa M, Havlin J, Riddell P, Chaparro CM, Singer LG, Liu L, Keshavjee S, Yeung JC, Martinu T. Oesophageal stasis is a risk factor for chronic lung allograft dysfunction and allograft failure in lung transplant recipients. ERJ Open Res 2023; 9:00222-2023. [PMID: 37817870 PMCID: PMC10561084 DOI: 10.1183/23120541.00222-2023] [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: 04/12/2023] [Accepted: 07/04/2023] [Indexed: 10/12/2023] Open
Abstract
Background Morbidity and mortality in lung transplant recipients are often triggered by recurrent aspiration events, potentiated by oesophageal and gastric disorders. Previous small studies have shown conflicting associations between oesophageal function and the development of chronic lung allograft dysfunction (CLAD). Herein, we sought to investigate the relationship between oesophageal motility disorders and long-term outcomes in a large retrospective cohort of lung transplant recipients. Methods All lung transplant recipients at the Toronto Lung Transplant Program from 2012 to 2018 with available oesophageal manometry testing within the first 7 months post-transplant were included in this study. Patients were categorised according to the Chicago Classification of oesophageal disorders (v3.0). Associations between oesophageal motility disorders with the development of CLAD and allograft failure (defined as death or re-transplantation) were assessed. Results Of 487 patients, 57 (12%) had oesophagogastric junction outflow obstruction (OGJOO) and 47 (10%) had a disorder of peristalsis (eight major, 39 minor). In a multivariable analysis, OGJOO was associated with an increased risk of CLAD (HR 1.71, 95% CI 1.15-2.55, p=0.008) and allograft failure (HR 1.69, 95% CI 1.13-2.53, p=0.01). Major disorders of peristalsis were associated with an increased risk of CLAD (HR 1.55, 95% CI 1.01-2.37, p=0.04) and allograft failure (HR 3.33, 95% CI 1.53-7.25, p=0.002). Minor disorders of peristalsis were not significantly associated with CLAD or allograft failure. Conclusion Lung transplant recipients with oesophageal stasis characterised by OGJOO or major disorders of peristalsis were at an increased risk of adverse long-term outcomes. These findings will help with risk stratification of lung transplant recipients and personalisation of treatment for aspiration prevention.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Juan C. Fernández-Castillo
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Peter Riddell
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Cecilia M. Chaparro
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Lianne G. Singer
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Li Y, Duan Z. Updates in interaction of gastroesophageal reflux disease and extragastroesophageal digestive diseases. Expert Rev Gastroenterol Hepatol 2022; 16:1053-1063. [PMID: 35860994 DOI: 10.1080/17474124.2022.2056018] [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] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is one of the common chronic diseases with prevalence increasing in the last decades. Because of its prevalence and chronicity, GERD affects the quality of life and increases health-care costs. Gastroesophageal diseases leading to GERD have been thoroughly studied, while extragastroesophageal digestive diseases (EGEDDs) may coexist with GERD and affect the occurrence and persistence of GERD symptoms and therapeutic effect. AREAS COVERED In this review, we aim to summarize the EGEDDs correlated with GERD and explore the potential mechanisms of this interaction. EXPERT OPINION Individuals with troublesome GERD symptoms may have some common gastroesophageal etiologies, but EGEDDs may also overlap and impact on the progression of GERD, which are often ignored in clinic. The lesions in the small intestine, colon, and hepatobiliary tract as well as functional bowel disorders had positive or negative associations with GERD through potential mechanisms. These diseases aggravate GERD symptoms, increase the esophageal acid burden, cause esophageal hypersensitivity, and finally affect the response to therapy in GERD patients. Therefore, it is necessary to clear the interaction between GERD and EGEDDs and their mechanisms.
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Affiliation(s)
- Yanqiu Li
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Zhijun Duan
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Jadcherla AV, Litzenberg K, Balasubramanian G. Esophageal Dysfunction in Post-lung Transplant: An Enigma. Dysphagia 2022; 38:731-743. [PMID: 35960395 DOI: 10.1007/s00455-022-10508-3] [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: 11/09/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.
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Affiliation(s)
| | - Kevin Litzenberg
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, Gastrointestinal Motility Laboratory, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd Floor, Columbus, OH, USA.
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