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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.
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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.
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2
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Zhang N, Liu S, Zhang Z, Liu Y, Mi L, Xu K. Lung Transplantation: A Viable Option for Connective Tissue Disease? Arthritis Care Res (Hoboken) 2023; 75:2389-2398. [PMID: 37052523 DOI: 10.1002/acr.25133] [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: 02/10/2023] [Revised: 03/24/2023] [Accepted: 04/11/2023] [Indexed: 04/14/2023]
Abstract
Interstitial lung disease (ILD) and pulmonary hypertension (PH) caused by connective tissue disease (CTD) are one of the main causes of morbidity and death in patients. Although the International Society for Heart & Lung Transplant suggested that ILD and PH related to CTD are rare indications for lung transplantation in 2006, many lung transplantation centers are concerned that the multisystem involvement of CTD will affect survival outcomes after lung transplantation, and CTD is regarded as a relative contraindication for lung transplantation. However, long-term and short-term survival after lung transplantation in CTD patients is similar compared with survival in common indications for lung transplantation such as idiopathic pulmonary fibrosis (IPF), and no higher incidence of complications after transplantation in many lung transplant centers. This suggests that lung transplantation may be beneficial in CTD patients with disease that progresses to end-stage lung disease, and CTD should not be considered a contraindication for lung transplantation. In the future, more prospective studies are needed to analyze the risk factors of lung transplantation in CTD patients to improve survival rates and reduce the risk of complications. This narrative review summarizes the selection and evaluation of candidates for CTD before lung transplantation and describes the clinical outcomes in CTD after lung transplantation in large-capacity lung transplantation center. The purpose of this review is to help rheumatologists decide when to refer patients with CTD-related lung involvement to a lung transplantation center and the conditions to consider before transplantation and to provide confidence to lung transplant experts.
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Affiliation(s)
- Na Zhang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shizhou Liu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaoliang Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, China
| | - Ying Liu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liangyu Mi
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, China
| | - Ke Xu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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Lo WK, Hiramoto B, Goldberg HJ, Sharma N, Chan WW. Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux. World J Gastroenterol 2023; 29:3292-3301. [PMID: 37377592 PMCID: PMC10292138 DOI: 10.3748/wjg.v29.i21.3292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux is associated with poorer outcomes after lung transplant, likely through recurrent aspiration and allograft injury. Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes, the role of esophageal manometry in the assessment of lung transplant patients remains debated, and the impact of esophageal dysmotility on transplant outcomes is unclear. Of particular interest is ineffective esophageal motility (IEM) and its associated impact on esophageal clearance.
AIM To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.
METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018. Patients with pre-transplant anti-reflux surgery were excluded. Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing. Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection, defined histologically per International Society of Heart and Lung Transplantation guidelines. Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery, last clinic visit, or death. Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.
RESULTS Of 184 subjects (54% men, mean age: 58, follow-up: 443 person-years) met criteria for inclusion. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis (41%). During the follow-up period, 60 subjects (33.5%) developed acute rejection. The all-cause mortality was 16.3%. Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection [hazard ratio (HR): 1.984, 95%CI: 1.03-3.30, P = 0.04], confirmed on Kaplan-Meier curve. On multivariable analysis, IEM remained independently associated with acute rejection, even after controlling for potential confounders such as the presence of acid and nonacid reflux (HR: 2.20, 95%CI: 1.18-4.11, P = 0.01). Nonacid reflux was also independently associated with acute rejection on both univariate (HR: 2.16, 95%CI: 1.26-3.72, P = 0.005) and multivariable analyses (HR: 2.10, 95%CI: 1.21-3.64, P = 0.009), adjusting for the presence of IEM.
CONCLUSION Pre-transplant IEM was associated with acute rejection after transplantation, even after controlling for acid and nonacid reflux. Esophageal motility testing may be considered in lung transplant to predict outcomes.
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Affiliation(s)
- Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Brent Hiramoto
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Nirmal Sharma
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
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Reedy EL, Simpson AN, O'Rourke AK, Bonilha HS. Characterizing Swallowing Impairment in a Post-Lung Transplant Population. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1236-1251. [PMID: 37000923 DOI: 10.1044/2023_ajslp-22-00266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population. METHOD A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored. RESULTS Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009. CONCLUSIONS Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.
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Affiliation(s)
- Erin L Reedy
- Health Sciences and Research, The Medical University of South Carolina, Charleston
| | - Annie N Simpson
- Health Sciences and Research, The Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
| | - Heather Shaw Bonilha
- Health Sciences and Research, The Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA
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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.
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Crespo MM, Claridge T, Domsic RT, Hartwig M, Kukreja J, Stratton K, Chan KM, Molina M, Ging P, Cochrane A, Hoetzenecker K, Ahmad U, Kapnadak S, Timofte I, Verleden G, Lyu D, Quddus S, Davis N, Porteous M, Mallea J, Perch M, Distler O, Highland K, Magnusson J, Vos R, Glanville AR. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part III: Pharmacology, medical and surgical management of post-transplant extrapulmonary conditions statements. J Heart Lung Transplant 2021; 40:1279-1300. [PMID: 34474940 DOI: 10.1016/j.healun.2021.07.013] [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: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022] Open
Abstract
Patients with connective tissues disease (CTD) are often on immunomodulatory agents before lung transplantation (LTx). Till now, there's no consensus on the safety of using these agents perioperative and post-transplant. The International Society for Heart and Lung Transplantation-supported consensus document on LTx in patients with CTD addresses the risk and contraindications of perioperative and post-transplant management of the biologic disease-modifying antirheumatic drugs (bDMARD), kinase inhibitor DMARD, and biologic agents used for LTx candidates with underlying CTD, and the recommendations and management of non-gastrointestinal extrapulmonary manifestations, and esophageal disorders by medical and surgical approaches for CTD transplant recipients.
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Affiliation(s)
- Maria M Crespo
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Tamara Claridge
- Department of Pharmacy, Hospital of the University of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robyn T Domsic
- Division of Rheumatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jasleen Kukreja
- Division of Thoracic Surgery, University of California San Francisco, San Francisco, California
| | - Kathleen Stratton
- Department of Pharmacy, Hospital of the University of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin M Chan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Maria Molina
- Department of Pharmacy, Hospital of the University of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Adam Cochrane
- Department of Pharmacy, Inova Fairfax Hospital, Falls Church, Virginia
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Usman Ahmad
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Siddhartha Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Irina Timofte
- Division of Pulmonary, University of Maryland Medical System, Baltimore, Maryland
| | - Geert Verleden
- Lung Transplant Unit, University Hospital of Gasthuisberg, Leuven, Belgium
| | - Dennis Lyu
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Sana Quddus
- Division of Pulmonary and Critical Care Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Nicole Davis
- Lung Transplant Program, Tampa General Hospital, Tampa, Florida
| | - Mary Porteous
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jorge Mallea
- Division of Pulmonary, Allergy, and Critical Care, Mayo Clinic Florida, Jacksonville, Florida
| | - Michael Perch
- Lung Transplant Program, Rigshospitalet, Copenhagen, Denmark
| | - Olivier Distler
- Department of Rheumatology, University of Zurich Medical Center, Zurich, Switzerland
| | | | - Jesper Magnusson
- Department of Pulmonology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robin Vos
- Lung Transplant Unit, University Hospital of Gasthuisberg, Leuven, Belgium
| | - Allan R Glanville
- The Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
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Csucska M, Razia D, Masuda T, Omar A, Giulini L, Smith MA, Walia R, Bremner RM, Mittal SK. Bilateral Lung Transplant for a Connective Tissue Disorder: Esophageal Motility and 3-year Survival. Semin Thorac Cardiovasc Surg 2021; 34:1065-1073. [PMID: 34144147 DOI: 10.1053/j.semtcvs.2021.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/04/2021] [Indexed: 02/07/2023]
Abstract
Connective tissue disorders (CTDs) are associated with esophageal dysmotility and gastroesophageal reflux disease, which may diminish survival after lung transplantation (LTx). We studied LTx outcomes in patients with a CTD stratified by esophageal motility. We identified patients who underwent bilateral LTx from 2012 to 2017. Patients with a CTD were classified by pre-LTx diagnosis: absent esophageal motility (AEM), ineffective esophageal motility (IEM), or preserved esophageal motility (PEM). The primary endpoint was 3-year survival. Sub-analysis compared survival between the AEM group and a propensity-matched (lung allocation score), non-CTD control group. Kaplan-Meier method and log-rank test were used. In total, 495 patients underwent LTx; 33 (6.7%) had a CTD. Median (IQR) age was 62 years (55.5-67.0); 24 (72.7%) were women. Survival trended lower for recipients with a CTD than without a CTD at 1-year (84.8% vs 91.8%; p = 0.2) and 3-years (66.7% vs 73.5%; p = 0.5). Within the CTD cohort, 1- and 3-year survival was significantly higher in the PEM (100%, 87.5%) and IEM (100%, 85.7%) groups than in the AEM group (50%, 20%; p < 0.001). The AEM group had significantly lower survival at 1-year (50% vs 92.5%) and 3-years (20% vs 65%) than a lung allocation score-matched cohort of patients without a CTD. LTx recipients with a CTD and AEM had significantly lower survival than those with PEM or IEM as well as significantly lower survival than that of a propensity-matched cohort of patients without a CTD. Patients with a CTD and AEM should be considered for LTx with extreme caution and counseled appropriately.
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Affiliation(s)
- Máté Csucska
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona
| | - Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona
| | - Takahiro Masuda
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona.
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Young JS, Coppolino A. Esophageal disease in lung transplant patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:900. [PMID: 34164534 PMCID: PMC8184450 DOI: 10.21037/atm-20-4934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
There is a very well-established and complex interplay between gastroesophageal reflux and lung disease. This is particularly true in end-stage lung disease and post-lung transplant patients. Numerous studies have shown that in patients who are undergoing pre-lung transplant evaluations for diseases such as idiopathic pulmonary fibrosis (IPF), emphysema, connective tissue disease, there is a high prevalence of gastroesophageal reflux and esophageal dysmotility. Post-lung transplant, many of the reflux issues persist or worsen, and there is some evidence to suggest that this leads to worsened long-term allograft function and bronchiolitis obliterans. Anti-reflux operations in patients with lung disease have been shown to be safe in both the pre and post-lung transplant setting and lead to improved reflux symptoms, as well as protecting against reflux induced allograft dysfunction in the post-lung transplant patients. Barrett’s esophagus and esophageal malignancy are also not unheard of in these patients, and select patients may benefit from operative intervention. This review discusses the links between gastroesophageal reflux and lung transplant patients in both the pre and post-transplant setting. We also review the approach to the workup of esophageal disease in the pre-lung transplant setting as well as the surgical management of this unique group of patients.
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Affiliation(s)
- John S Young
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Antonio Coppolino
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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9
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Abstract
PURPOSE OF REVIEW Over the past two decades, lung transplant has become the mainstay of treatment for several end-stage lung diseases. As the field continues to evolve, the criteria for referral and listing have also changed. The last update to these guidelines was in 2014 and several studies since then have changed how patients are transplanted. Our article aims to briefly discuss these updates in lung transplantation. RECENT FINDINGS This article discusses the importance of early referral of patients for lung transplantation and the concept of the 'transplant window'. We review the referral and listing criteria for some common pulmonary diseases and also cite the updated literature surrounding the absolute and relative contraindications keeping in mind that they are a constantly moving target. Frailty and psychosocial barriers are difficult to assess with the current assessment tools but continue to impact posttransplant outcomes. Finally, we discuss the limited data on transplantation in acute respiratory distress syndrome (ARDS) due to COVID19 as well as extracorporeal membrane oxygenation bridge to transplantation. SUMMARY The findings discussed in this article will strongly impact, if not already, how we select candidates for lung transplantation. It also addresses some aspects of lung transplant such as frailty and ARDS, which need better assessment tools and clinical data.
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10
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Yang X, Wei D, Liu M, Wu B, Zhang J, Xu H, Ye S, Liu F, Hu C, Chen J. Survival and outcomes after lung transplantation for connective tissue disease-associated interstitial lung diseases. Clin Rheumatol 2021; 40:3789-3795. [PMID: 33755837 PMCID: PMC7985740 DOI: 10.1007/s10067-021-05704-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/22/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022]
Abstract
Background Lung transplantation (LTx) is the most important treatment for end-stage lung diseases. However, the treatment of connective tissue disease-associated interstitial lung diseases (CTD-ILD) using LTx is still controversial especially for polymyositis/dermatomyositis-associated interstitial lung disease (PM/DM-ILD). Methods Patients diagnosed with idiopathic pulmonary fibrosis (IPF) (n=180) and CTD-ILD (n= 36) from 1st January 2015 to 31st December 2019 were recruited into the study. We set polymyositis/dermatomyositis (PM/DM) as a single subgroup, and all the patients underwent LTx at the Wuxi People’s Hospital. Results We found that patients with non-myositis connective tissue-related ILD (NM-CTLD) were younger (p=0.007) and had a higher percentage of females (p=0.000) than patients with IPF. PM/DM-ILD was associated with a higher incidence of primary graft dysfunction (PGD) (p=0.006) and a longer time in the intensive care unit (ICU) (p=0.000). The cumulative survival rates of patients with PM/DM-ILD were significantly lower than those with IPF (log rank, p=0.003). However, there were no significant differences when compared with the cumulative survival rates of patients with NM-CTLD and IPF (log rank, p=0.528). Age- and gender-adjusted Cox proportional hazard analyses indicated that post-LTx PGD (HR 1.498, 95% CI 1.227–1.828, p=0.000) and duration of ICU (HR 1.027, 95% CI 1.007–1.047, p=0.000) were the independent contributors of disease status to survival. Lung infection was the leading cause of post-LTx death in the groups, where the incidence was 65.3% (47/72) in IPF, 66.7% (8/12) in NM-CTLD, and 66.7% (4/6) in PM/DM-ILD. Conclusions This study found that patients with NM-CTLD had a similar survival outcome with IPF. However, patients with PM/DM-ILD-performed LTx had a lower survival rate than those with IPF.
Key Points • Previous studies have shown that the myopathies associated ILD patients had similar post-LTx outcomes with IPF patients. However, our retrospective analysis indicated that patients with PM/DM-ILD-performed LTx had a lower survival rate than those with IPF. • Patients with NM-CTLD had a similar survival outcome with IPF. • We also found that PM/DM-ILD was associated with a higher incidence of PGD and a longer time in the ICU. |
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Affiliation(s)
- Xiucheng Yang
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Dong Wei
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Mingzhao Liu
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Bo Wu
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Ji Zhang
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Hongyang Xu
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Shugao Ye
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Feng Liu
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Chunxiao Hu
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Jingyu Chen
- Lung Transplant Center, Department of Thoracic Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China.
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Kovacs B, Masuda T, Bremner RM, Mittal SK. Clinical spectrum and presentation of patients with absent contractility. Ann Gastroenterol 2021; 34:331-336. [PMID: 33948057 PMCID: PMC8079877 DOI: 10.20524/aog.2021.0583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 11/18/2020] [Indexed: 01/09/2023] Open
Abstract
Background Primary absent contractility is an uncommon finding on high-resolution manometry (HRM). The goal of this study was to describe the clinical spectrum and presentation of patients with primary absent contractility. Methods We queried a prospectively maintained esophageal testing registry to identify patients with absent contractility who presented between August 2016 and September 2018. Patients with poor quality studies and patients with insufficient clinical records as well as those with a history of previous foregut surgery or esophagram consistent with achalasia were excluded. Results A total of 2068 patients underwent HRM during the study period. Of these, 66 patients (3.2%) met the inclusion criteria and formed the study cohort; 52 patients in the cohort had an upper gastrointestinal contrast study, 50 had endoscopy, and 51 completed a foregut symptom questionnaire. Thirty-eight patients (57.6%) were women. The mean age was 56.6±13.86 years, and the mean body mass index was 26.37±5.7 kg/m2. Almost half of the patients (29/66, 43.9%) were undergoing lung transplant evaluation, and 22 patients (37.3%) had a history of autoimmune immune-mediated or myopathic diseases. On the symptom questionnaire, 42 of 51 patients (82.3%) reported heartburn, 24 of 51 (47.1%) reported dysphagia, and 23 of 51 patients (45.1%) reported both. On ambulatory pH monitoring, 23 of 37 patients (62.2%) had pathological esophageal acid exposure (acid exposure time >6%). Conclusions Absent contractility on HRM is uncommon and is frequently associated with connective tissue, myopathic or autoimmune disorders. The usual clinical presentation is reflux, dysphagia or both.
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Affiliation(s)
- Balazs Kovacs
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center (Balazs Kovacs, Takahiro Masuda, Ross M. Bremner, Sumeet K. Mittal)
| | - Takahiro Masuda
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center (Balazs Kovacs, Takahiro Masuda, Ross M. Bremner, Sumeet K. Mittal).,Creighton University School of Medicine, Phoenix Regional Campus (Takahiro Masuda, Sumeet K. Mittal), Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center (Balazs Kovacs, Takahiro Masuda, Ross M. Bremner, Sumeet K. Mittal)
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center (Balazs Kovacs, Takahiro Masuda, Ross M. Bremner, Sumeet K. Mittal).,Creighton University School of Medicine, Phoenix Regional Campus (Takahiro Masuda, Sumeet K. Mittal), Phoenix, AZ, USA
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12
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Jee AS, Sheehy R, Hopkins P, Corte TJ, Grainge C, Troy LK, Symons K, Spencer LM, Reynolds PN, Chapman S, de Boer S, Reddy T, Holland AE, Chambers DC, Glaspole IN, Jo HE, Bleasel JF, Wrobel JP, Dowman L, Parker MJS, Wilsher ML, Goh NSL, Moodley Y, Keir GJ. Diagnosis and management of connective tissue disease-associated interstitial lung disease in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand. Respirology 2020; 26:23-51. [PMID: 33233015 PMCID: PMC7894187 DOI: 10.1111/resp.13977] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/26/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Pulmonary complications in CTD are common and can involve the interstitium, airways, pleura and pulmonary vasculature. ILD can occur in all CTD (CTD-ILD), and may vary from limited, non-progressive lung involvement, to fulminant, life-threatening disease. Given the potential for major adverse outcomes in CTD-ILD, accurate diagnosis, assessment and careful consideration of therapeutic intervention are a priority. Limited data are available to guide management decisions in CTD-ILD. Autoimmune-mediated pulmonary inflammation is considered a key pathobiological pathway in these disorders, and immunosuppressive therapy is generally regarded the cornerstone of treatment for severe and/or progressive CTD-ILD. However, the natural history of CTD-ILD in individual patients can be difficult to predict, and deciding who to treat, when and with what agent can be challenging. Establishing realistic therapeutic goals from both the patient and clinician perspective requires considerable expertise. The document aims to provide a framework for clinicians to aid in the assessment and management of ILD in the major CTD. A suggested approach to diagnosis and monitoring of CTD-ILD and, where available, evidence-based, disease-specific approaches to treatment have been provided.
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Affiliation(s)
- Adelle S Jee
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Robert Sheehy
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Peter Hopkins
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Queensland Lung Transplant service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Christopher Grainge
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Respiratory Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Lauren K Troy
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Karen Symons
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Lissa M Spencer
- Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul N Reynolds
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Lung Research Laboratory, University of Adelaide, Adelaide, SA, Australia
| | - Sally Chapman
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sally de Boer
- Respiratory Services, Auckland District Health Board, Auckland, New Zealand
| | - Taryn Reddy
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Anne E Holland
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, VIC, Australia.,Department of Physiotherapy, Alfred Health, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia
| | - Daniel C Chambers
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Queensland Lung Transplant service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Ian N Glaspole
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Helen E Jo
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Jane F Bleasel
- Central Clinical School, University of Sydney, Sydney, NSW, Australia.,Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jeremy P Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Leona Dowman
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, VIC, Australia.,Physiotherapy Department, Austin Health, Melbourne, VIC, Australia
| | - Matthew J S Parker
- Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Margaret L Wilsher
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Respiratory Services, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Nicole S L Goh
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia.,Department of Respiratory Medicine, Austin Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Yuben Moodley
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,University of Western Australia, Institute for Respiratory Health, Perth, WA, Australia.,Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Gregory J Keir
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
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13
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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.
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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
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14
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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: 34] [Impact Index Per Article: 8.5] [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.
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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
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15
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Panchabhai TS, Abdelrazek HA, Bremner RM. Lung Transplant in Patients with Connective Tissue Diseases. Clin Chest Med 2019; 40:637-654. [DOI: 10.1016/j.ccm.2019.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Lung Transplantation in Connective Tissue Disease-Associated Interstitial Lung Disease (CTD-ILD). CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0207-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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17
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Park JE, Kim SY, Song JH, Kim YS, Chang J, Lee JG, Paik HC, Park MS. Comparison of short-term outcomes for connective tissue disease-related interstitial lung disease and idiopathic pulmonary fibrosis after lung transplantation. J Thorac Dis 2018; 10:1538-1547. [PMID: 29707304 DOI: 10.21037/jtd.2018.02.50] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Pulmonary involvement is common in connective tissue disease (CTD), and respiratory failure is a major cause of morbidity and mortality in CTD-related interstitial lung disease (CTD-ILD). Lung transplantation is thus important for these patients. However, survival, outcomes, and management of these patients after transplantation have been debated. The aim of this study was to evaluate the outcomes for CTD-ILD compared to those for idiopathic pulmonary fibrosis (IPF) after lung transplantation. Methods We performed a single-centre retrospective study of 62 patients with CTD-ILD or IPF who underwent lung transplantation at a tertiary hospital in South Korea between October 2012 and October 2016. Results Patients with CTD-ILD (n=15) were younger (46 vs. 60 years, P=0.001) and were less likely to be male (33.3% vs. 76.6%, P=0.004) than were patients with IPF (n=47). The 1-year cumulative survival rate was 80.0% for CTD-ILD and 59.6% for IPF (log-rank P=0.394). There was no difference in the cumulative survival rate (log-rank P=0.613) of age- and sex-matched patients with CTD-ILD (n=15) and IPF (n=15). The incidence of primary graft dysfunction was similar (P=0.154), and 2 (18.2%) patients developed possible CTD flare. Conclusions Patients with CTD-ILD and those with IPF who underwent lung transplantation had similar survival rates.
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Affiliation(s)
- Ji Eun Park
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Han Song
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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18
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Fernández-Codina A, Berastegui C, Pinal-Fernández I, Silveira MG, López-Meseguer M, Monforte V, Guillén-del Castillo A, Simeón-Aznar CP, Fonollosa-Plà V, Solé J, Bravo-Masgoret C, Román-Broto A. Lung transplantation in systemic sclerosis: A single center cohort study. Joint Bone Spine 2018; 85:79-84. [DOI: 10.1016/j.jbspin.2017.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
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19
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Abstract
PURPOSE OF REVIEW The purpose of this study was to highlight recent findings on evaluation for lung transplantation and outcomes after transplantation in patients with systemic sclerosis (scleroderma). RECENT FINDINGS The recognition that extra-pulmonary disease manifestations can seriously compromise post-transplant outcomes has changed the way patients are screened for lung transplant candidacy. Reluctance to transplant subjects affected by scleroderma has been driven by the complexity and multisystem nature of this disease. Multiple recent reports provide convincing findings that scleroderma patients undergoing lung transplantation have similar outcomes as those with other non-rheumatologic pulmonary conditions, even when significant esophageal dysmotility is present. New evidence supports the notion that scleroderma should not be a contraindication for referral to lung transplant. Future studies are needed to improve risk stratification, to define protocols for screening and management of extra-pulmonary complications, and to optimize immunosuppression before and after transplant.
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20
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Kimmel JN, Carlson DA, Hinchcliff M, Carns MA, Aren KA, Lee J, Pandolfino JE. The association between systemic sclerosis disease manifestations and esophageal high-resolution manometry parameters. Neurogastroenterol Motil 2016; 28:1157-65. [PMID: 26921101 PMCID: PMC4956560 DOI: 10.1111/nmo.12813] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 02/03/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND We aimed to evaluate the associations between systemic sclerosis (SSc)-related systemic manifestations and esophageal function using high-resolution manometry (HRM). METHODS Patients with SSc that had undergone HRM between 1/2004 and 9/2014 were identified and HRMs were analyzed according to the Chicago Classification. Clinical characteristics were identified via retrospective chart review and compared among motility diagnoses while adjusting for age, gender, race, and SSc-disease duration. KEY RESULTS Seventy-nine patients (85% female, ages 25-77) were included. Clinical characteristics were compared between patients with absent contractility (AC, n = 40), ineffective esophageal motility (IEM; n = 15), and normal motility (n = 19); the five remaining patients met criteria for other motility diagnoses. Groups differed in severity of skin involvement measured by the modified Rodnan skin score (0-51): AC (adjusted mean 12.6), IEM (4.4), normal (4.3), p = 0.043. Pulmonary function tests [percent predicted FVC and DLCO) were lower in AC (adjusted mean, FVC: 70.3, DLCO 51.1), than IEM (FVC: 92.0; DLCO: 76.9) and normal motility (FVC: 80.0; DLCO: 67.2), p values 0.057 (FVC) and 0.007 (DLCO). Groups did not differ by SSc-disease duration, autoantibodies, or reported symptoms of dysphagia or reflux. CONCLUSIONS & INFERENCES In patients with SSc, absent esophageal contractility on HRM was associated with increased skin disease severity and worse lung function. Obtaining HRM to identify SSc patients with more severe esophageal dysfunction could be considered to enable implementation of management strategies in patients potentially at risk for increased morbidity and mortality.
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Affiliation(s)
- Jessica N. Kimmel
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Monique Hinchcliff
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary A. Carns
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kathleen A Aren
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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21
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Patti MG, Vela MF, Odell DD, Richter JE, Fisichella PM, Vaezi MF. The Intersection of GERD, Aspiration, and Lung Transplantation. J Laparoendosc Adv Surg Tech A 2016; 26:501-5. [PMID: 27218671 DOI: 10.1089/lap.2016.0170] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Lung transplantation is a radical but life-saving treatment option for patients with end-stage lung diseases, such as idiopathic pulmonary fibrosis (IPF) and scleroderma. In light of the proposed association and controversy linking gastroesophageal reflux disease (GERD) to IPF and lung transplant outcome, the American Gastroenterological Association convened during the DDW in Washington in May 2015 a multidisciplinary group of experts in the field of GERD and lung transplantation to make considerations about the care of these patients based on available data and subsequent expert panel discussion at this symposium. The following topics were discussed: (1) pathophysiology of GERD-induced pulmonary symptoms, (2) GERD evaluation before and after lung transplantation, (3) outcome of lung transplantation for IPF and scleroderma, and (4) role of laparoscopic fundoplication before or after lung transplantation.
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Affiliation(s)
- Marco G Patti
- 1 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
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22
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Gulack BC, Meza JM, Lin SS, Hartwig MG, Davis RD. Reflux and Allograft Dysfunction: Is There a Connection? Thorac Surg Clin 2015; 25:97-105. [DOI: 10.1016/j.thorsurg.2014.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Launay D, Savale L, Berezne A, Le Pavec J, Hachulla E, Mouthon L, Sitbon O, Lambert B, Gaudric M, Jais X, Stephan F, Hatron PY, Lamblin N, Vignaux O, Cottin V, Farge D, Wallaert B, Guillevin L, Simonneau G, Mercier O, Fadel E, Dartevelle P, Humbert M, Mussot S. Lung and heart-lung transplantation for systemic sclerosis patients. A monocentric experience of 13 patients, review of the literature and position paper of a multidisciplinary Working Group. Presse Med 2014; 43:e345-63. [DOI: 10.1016/j.lpm.2014.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/23/2014] [Indexed: 12/14/2022] Open
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24
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Fisichella PM, Reder NP, Gagermeier J, Kovacs EJ. Usefulness of pH monitoring in predicting the survival status of patients with scleroderma awaiting lung transplantation. J Surg Res 2014; 189:232-7. [PMID: 24726692 DOI: 10.1016/j.jss.2014.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/10/2014] [Accepted: 03/11/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with scleroderma and end-stage lung disease (ESLD) have a very high prevalence of gastroesophageal reflux disease (GERD). Because GERD has been associated with aspiration in those with ESLD, and because those with scleroderma are particularly prone to develop severe GERD, there is some concern that GERD may contribute to shorten survival in patients with scleroderma awaiting lung transplantation. Therefore, we hypothesized that esophageal pH monitoring could predict survival of those with scleroderma and ESLD awaiting lung transplantation and that the severity of reflux can impact survival. METHODS We conducted a retrospective analysis of all scleroderma patients referred for lung transplantation who underwent esophageal manometry and pH monitoring since August 2008. We identified 10 patients in whom we calculated and compared the area under the curve for each receiver operating characteristic curve of the following variables: DeMeester score, forced expiratory volume in 1 s (FEV1), %predicted FEV1, forced vital capacity (FVC), %predicted FVC, diffusion capacity for carbon monoxide (DLco), and %predicted DLco. RESULTS The DeMeester score nominally outperformed FEV1, FVC, and DLco. Receiver operating characteristic curve analysis was also used to define the optimal DeMeester score (65.2) in differentiating survival status, as determined by maximizing sensitivity and specificity. Based on this value, we calculated the 1-y survival from the time of the esophageal function testing, which was 100% in seven patients with a DeMeester score of <65.2, and 33% in three patients with a score >65.2 (P = 0.01). The latter patients had greater total time pH < 4, greater time pH < 4 in the supine position, greater total episodes of reflux, and higher prevalence of absent peristalsis. The single survivor with a DeMeester score >70 had also proximal reflux, underwent antireflux surgery, and is alive 1201 d after transplant. CONCLUSIONS Our study shows that esophageal pH monitoring can predict survival status in patients with scleroderma awaiting lung transplantation and that the severity of reflux can impact the 1-y survival rate. Therefore, esophageal pH monitoring should be considered early in patients with scleroderma and ESLD, as this test could appropriately identify those in whom laparoscopic antireflux surgery should be performed quicker to prevent GERD and its detrimental effects in patients awaiting lung transplantation.
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Affiliation(s)
| | - Nicholas P Reder
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - James Gagermeier
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Elizabeth J Kovacs
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
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25
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Fisichella PM, Jalilvand A. The role of impaired esophageal and gastric motility in end-stage lung diseases and after lung transplantation. J Surg Res 2014; 186:201-6. [DOI: 10.1016/j.jss.2013.09.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/07/2013] [Accepted: 09/18/2013] [Indexed: 01/29/2023]
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26
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Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment. J Gastrointest Surg 2014; 18:100-4; discussion 104-5. [PMID: 24002768 DOI: 10.1007/s11605-013-2333-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 08/20/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Even though the pathogenesis of idiopathic pulmonary fibrosis (IPF) is unknown, there is mounting evidence that abnormal reflux (GERD) and aspiration of gastric contents may play a role in the pathogenesis of this disease. AIMS The aims of this study were to determine in patients with GERD and IPF: (a) the clinical presentation, (b) the esophageal function, and (c) the reflux profile. METHODS We compared the clinical presentation, the esophageal function (as defined by high-resolution manometry), and the reflux profile (by dual sensor pH monitoring) in 80 patients with GERD (group A) and in 22 patients with GERD and IPF (group B). RESULTS Heartburn was present in less than 60 % of patients with GERD and IPF. Lower esophageal sphincter pressure and peristalsis were normal in both groups, while the upper esophageal sphincter (UES) was more frequently hypotensive in IPF patients (p = 0.008). In patients with GERD and IPF, the proximal esophageal acid exposure was higher (p = 0.047) and the supine acid clearance was slower as compared with patients with GERD only (p < 0.001). CONCLUSIONS The results of this study show that in patients with GERD and IPF: (a) reflux is frequently silent, (b) with the exception of a weaker UES, the esophageal function is preserved, and (c) proximal reflux is more common, and in the supine position, it is coupled with a slower acid clearance. Because these factors predisposing IPF patients to the risk of aspiration, antireflux surgery should be considered early after the diagnosis of IPF and GERD is established.
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Norfolk SG, Lederer DJ, Tapson VF. Lung transplantation and atrial septostomy in pulmonary arterial hypertension. Clin Chest Med 2013; 34:857-65. [PMID: 24267309 DOI: 10.1016/j.ccm.2013.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article summarizes the current literature regarding surgical interventions in pulmonary hypertension, excluding chronic thromboembolic pulmonary hypertension. The article discusses the use of atrial septostomy in patients meeting criteria as well as single, double, and heart-lung transplantation.
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Affiliation(s)
- Stephanie G Norfolk
- Division of Pulmonary and Critical Care, Duke University Medical Center, DUMC 102342, Durham, NC 27710, USA
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Khan IY, Singer LG, de Perrot M, Granton JT, Keshavjee S, Chau C, Kron A, Johnson SR. Survival after lung transplantation in systemic sclerosis. A systematic review. Respir Med 2013; 107:2081-7. [PMID: 24113572 DOI: 10.1016/j.rmed.2013.09.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 09/06/2013] [Accepted: 09/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lung transplantation is a life-saving option for systemic sclerosis (SSc)-associated pulmonary arterial hypertension (PAH) and interstitial lung disease (SSc-ILD) patients. However, some programs may be concerned about the possibility of excess post-transplantation mortality related to the extra-pulmonary manifestations of SSc. The objective of this study was to evaluate survival of SSc patients post-lung transplantation. We secondarily evaluated SSc lung transplant recipient characteristics (age, sex, and type of SSc lung disease), and discussed post-lung transplantation survival of SSc patients and non-SSc patients (idiopathic PAH, and ILD). METHODS A systematic review of MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials and CINAHL (all inception to 2012) was performed to identify studies evaluating post-lung transplant survival in SSc compared to PAH and ILD patients. Two reviewers independently abstracted study and survival data. RESULTS Two hundred twenty-six citations were screened to identify 7 observational studies reporting SSc patients who underwent single lung, double lung, or heart-lung transplantation. Mean age at transplantation ranged 46-53 years. SSc post-transplantation survival ranged 69%-91% at 30-days, 69%-85% at 6-months, 59%-93% at 1-year, 49%-80% at 2-years, and 46%-79% at 3-years. Causes of death included graft failure, infection, cardiac events, hemorrhagic stroke, respiratory failure, malignancy, pulmonary hypertension, complications of bronchiolitis obliterans syndrome, anesthetic complication, and scleroderma renal crisis. There were no reports of recurrence of SSc in the lung allograft. CONCLUSION The short-term and intermediate-term survival post-lung transplantation are similar to IPAH and ILD patients requiring lung transplantation.
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Affiliation(s)
- Irfan Y Khan
- Pulmonary Hypertension Programme, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Seccombe J, Mirza F, Hachem R, Gyawali CP. Esophageal motor disease and reflux patterns in patients with advanced pulmonary disease undergoing lung transplant evaluation. Neurogastroenterol Motil 2013; 25:657-63. [PMID: 23594384 DOI: 10.1111/nmo.12135] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 03/21/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND Advanced pulmonary disorders are linked to esophageal hypomotility and reflux disease. However, characterization of esophageal function using high resolution manometry (HRM) and ambulatory pH monitoring, segregation by pulmonary pathology, and comparison to traditional reflux disease are all limited in the literature. METHODS Over a 4 year period, 73 patients (55.2 ± 1.3 years, 44F) were identified who underwent esophageal function testing as part of lung transplant evaluation for advanced pulmonary disease (interstitial lung disease, ILD = 47, obstructive lung disease, OLD = 24, other = 2). Proportions of patients with motor dysfunction (≥ 80% failed sequences = severe hypomotility) and/or abnormal reflux parameters (acid exposure time, AET ≥ 4%) were determined, and compared to a cohort of 1081 patients (48.4 ± 0.4 years, 613F) referred for esophageal function testing prior to antireflux surgery (ARS). KEY RESULTS The proportion of esophageal body hypomotility was significantly higher within advanced pulmonary disease categories (35.6%), particularly ILD (44.7%), compared to ARS patients (12.1%, P < 0.0001). Abnormal AET was noted in 56.5%, and was similar between ILD and OLD, but less frequent than in the ARS group (P = 0.04). Post-transplant chronic rejection trended towards association with pretransplant elevated AET in OLD (P = 0.08) but not ILD. Mortality was not predicted by esophageal motor pattern or reflux evidence. CONCLUSIONS & INFERENCES Interstitial lung disease has a highly significant association with esophageal body hypomotility. Consequently, prevalence of abnormal esophageal acid exposure is high, but implications for post lung transplant chronic rejection remain unclear.
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Affiliation(s)
- J Seccombe
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Outcomes in systemic sclerosis-related lung disease after lung transplantation. Transplantation 2013; 95:975-80. [PMID: 23545509 DOI: 10.1097/tp.0b013e3182845f23] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lung disease is the leading cause of death in systemic sclerosis (SSc). The diagnosis of SSc-related lung disease (SSc-LD) is often a contraindication to lung transplantation (LT) due to concerns that extrapulmonary involvement will yield worse outcomes. We sought to evaluate posttransplantation outcomes in persons with SSc-LD with esophageal involvement compared with persons with nonconnective tissue disease-related interstitial lung disease (nCTD-ILD). METHODS From 1998 to 2012, persons undergoing LT for SSc-LD were age and gender matched in a 2:1 fashion to controls undergoing LT for nCTD-ILD. Esophageal function was assessed by pH testing and manometry. We defined esophageal dysfunction as the presence of a DeMeester score >14 or dysmotility more severe than "mild nonspecific disorder". The primary outcome was posttransplantation survival. Secondary outcomes included freedom from bronchiolitis obliterans syndrome (fBOS) and rates of acute rejection. Survival and fBOS were estimated with Kaplan-Meier methods. Acute rejection was compared with Student's t test. RESULTS Survival was similar in 23 persons with SSc-LD and 46 controls who underwent LT (P = 0.47). For the SSc-LD group, 1- and 5-year survival was 83% and 76% compared with 91% and 64% in the nCTD-ILD group, respectively. There were no differences in fBOS (P = 0.83). Rates of acute rejection were less in SSc-ILD (P = 0.05). Esophageal dysfunction was not associated with worse outcomes (P>0.55). CONCLUSIONS Persons with SSc-LD appear to have similar survival and fBOS as persons transplanted for nCTD-ILD. The risk of acute rejection after transplantation may be reduced in persons with SSc-LD. Esophageal involvement does not appear to impact outcomes.
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Antin-Ozerkis D, Rubinowitz A, Evans J, Homer RJ, Matthay RA. Interstitial lung disease in the connective tissue diseases. Clin Chest Med 2013; 33:123-49. [PMID: 22365251 DOI: 10.1016/j.ccm.2012.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The connective tissue diseases (CTDs) are inflammatory, immune-mediated disorders in which interstitial lung disease (ILD) is common and clinically important. Interstitial lung disease may be the first manifestation of a CTD in a previously healthy patient. CTD-associated ILD frequently presents with the gradual onset of cough and dyspnea, although rarely may present with fulminant respiratory failure. Infection and drug reaction should always be ruled out. A diagnosis of idiopathic ILD should never be made without a careful search for subtle evidence of underlying CTD. Treatment of CTD-ILD typically includes corticosteroids and immunosuppressive agents.
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Affiliation(s)
- Danielle Antin-Ozerkis
- Yale Interstitial Lung Disease Program, Pulmonary & Critical Care Medicine Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA.
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Gyawali CP, Bredenoord AJ, Conklin JL, Fox M, Pandolfino JE, Peters JH, Roman S, Staiano A, Vaezi MF. Evaluation of esophageal motor function in clinical practice. Neurogastroenterol Motil 2013; 25:99-133. [PMID: 23336590 DOI: 10.1111/nmo.12071] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics.
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Affiliation(s)
- C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.
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Soares RV, Forsythe A, Hogarth K, Sweiss NJ, Noth I, Patti MG. Interstitial lung disease and gastroesophageal reflux disease: key role of esophageal function tests in the diagnosis and treatment. ARQUIVOS DE GASTROENTEROLOGIA 2012; 48:91-7. [PMID: 21709948 DOI: 10.1590/s0004-28032011000200002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 01/13/2011] [Indexed: 12/16/2022]
Abstract
CONTEXT Gastroesophageal reflux disease (GERD) is common in patients with respiratory disorders and interstitial lung fibrosis from diverse disease processes. However, a cause-effect relationship has not been well demonstrated. It is hypothesized that there might be more than a coincidental association between GERD and interstitial lung damage. There is still confusion about the diagnostic steps necessary to confirm the presence of GERD, and about the role of effective control of GERD in the natural history of these respiratory disorders. OBJECTIVES To determine the prevalence of GERD in patients with respiratory disorders and lung involvement; the sensitivity of symptoms in the diagnosis of GERD; and the role of esophageal function tests (manometry and 24- hour pH monitoring) in the diagnosis and treatment of these patients. METHODS Prospective study based on a database of 44 patients (29 females) with respiratory disorders: 16 patients had idiopathic pulmonary fibrosis, 11 patients had systemic sclerosis associated interstitial lung disease, 2 patients had polymyositis associated interstitial lung disease, 2 patients had Sjögren associated interstitial lung disease, 2 patients had rheumatoid artrithis associated interstitial lung disease, 1 patient had undifferentiated connective tissue diseases associated interstitial lung disease and 10 patients had sarcoidosis. The average forced vital capacity (% predicted) was 64.3%. All patients had esophageal function tests. RESULTS Thirty patients (68%) had pathologic reflux (average DeMeester score: 45, normal <14.7). The average number of reflux episodes recorded 20 cm above the lower esophageal sphincter was 24. Sensitivity and specificity of heartburn were 70% and 57%, of regurgitation 43% and 57%, and of dysphagia 33% and 64%. Twelve patients with GERD underwent a laparoscopic fundoplication which was tailored to the manometric profile: three patients in which peristalsis was normal had a total fundoplication (360°) and nine patients in which the peristalsis was absent had a partial anterior fundoplication (180°). CONCLUSIONS The results of our study show that: (a) abnormal reflux was present in about 2/3 of patients with respiratory disorders (idiophatic pulmonary fibrosis, connective tissue disorders and sarcoidosis), and it extended to the upper esophagus in most patients; (b) the sensitivity and specificity of reflux symptoms was very low; and (c) esophageal function tests were essential to establish the diagnosis of abnormal reflux, to characterize the esophageal function and guide therapy. Long term follow-up will be necessary to determine if control of reflux alters the natural history of these respiratory disorders.
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Affiliation(s)
- Renato Vianna Soares
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, USA.
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Sem M, Lund MB, Molberg O. Long-term outcome of lung transplantation in a patient with the anti-synthetase syndrome. Scand J Rheumatol 2011; 40:327-8. [PMID: 21623666 DOI: 10.3109/03009742.2011.566280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
In the last 45 years, lung transplantation has evolved from its status as a rare extreme form of surgical therapy for the treatment of advanced lung diseases to an accepted therapeutic option for select patients. Although pulmonary fibrosis and pulmonary vascular diseases are important indications for lung transplantation, only a small percentage of transplants are performed in patients with collagen vascular diseases. The reasons for this low number are multifactorial. This article reviews issues relevant to all lung transplant candidates and recipients as well as those specific to patients with autoimmune diseases.
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Affiliation(s)
- James C Lee
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Saggar R, Khanna D, Furst DE, Belperio JA, Park GS, Weigt SS, Kubak B, Ardehali A, Derhovanessian A, Clements PJ, Shapiro S, Hunter C, Gregson A, Fishbein MC, Lynch Iii JP, Ross DJ, Saggar R. Systemic sclerosis and bilateral lung transplantation: a single centre experience. Eur Respir J 2010; 36:893-900. [PMID: 20351032 DOI: 10.1183/09031936.00139809] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lung involvement is the leading cause of death in systemic sclerosis (SSc), but lung transplantation (LT) for systemic disease remains controversial. Our objective was to comprehensively evaluate post-LT outcomes for SSc compared to idiopathic pulmonary fibrosis (IPF). We retrospectively evaluated bilateral LT recipients (LTRs) with SSc or IPF at our centre between January 1, 2003 and December 31, 2007. The primary end-point was all-cause mortality at 1 yr post-LT. Secondary end-points included assessments of acute rejection (AR), pulmonary function, infection and chronic rejection. 14 patients with SSc and 38 patients with IPF underwent LT. Apart from a younger SSc cohort (53.2 versus 58.8 yrs; p = 0.02), the two groups were well matched. 1-yr all-cause mortality was no different between SSc (6.6%) and IPF (13.1%) groups, after adjusting for age (p = 0.62). Rates of (AR) ≥2 were significantly increased for the SSc compared with the IPF group (hazard ratio (HR) 2.91; p = 0.007). Other end-points, including chronic rejection, infection and pulmonary function, showed no differences. SSc LTRs experience similar survival 1 yr post-LT when compared to IPF. AR rates may be significantly higher in the SSc group. Longer follow-up is necessary to determine the effects of gastrointestinal dysfunction and AR on late allograft function in SSc LTR.
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Affiliation(s)
- R Saggar
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1690, USA.
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