Pretransplant gastroesophageal reflux compromises early outcomes after lung transplantation

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
The Journal of thoracic and cardiovascular surgery (Impact Factor: 4.17). 07/2011; 142(1):47-52.e3. DOI: 10.1016/j.jtcvs.2011.04.028
Source: PubMed


Gastroesophageal reflux disease (GERD) is implicated as a risk factor for bronchiolitis obliterans syndrome after lung transplantation, but its effects on acute rejection, early allograft function, and survival are unclear. Therefore, we sought to systematically understand the time-related impact of pretransplant GERD on graft function (spirometry), mortality, and acute rejection early after lung transplantation.
From January 2005 to July 2008, 215 patients underwent lung transplantation; 114 had preoperative pH testing, and 32 (28%) had objective evidence of GERD. Lung function was assessed by forced 1-second expiratory volume (FEV(1); percent of predicted) in 97 patients, mortality by follow-up (median, 2.2 years), and acute rejection by transbronchial biopsy.
Pretransplant GERD was associated with decreased FEV(1) early after lung transplantation (P = .01) such that by 18 months, FEV(1) was 70% of predicted in double lung transplant patients with GERD versus 83% among non-GERD patients (P = .05). A similar decrease was observed in single lung transplantation (50% vs 60%, respectively; P = .09). GERD patients had lower survival early after transplant ( P = .02)-75% versus 90%. Presence of GERD did not affect acute rejection (P = .6).
For lung transplant recipients, pretransplant GERD is associated with worse early allograft function and survival, but not increased acute rejection. The compromise in lung function is substantial, such that FEV(1) after double lung transplant in GERD patients approaches that of single lung transplant in non-GERD patients. We advocate thorough testing for GERD before lung transplantation; if identified, aggressive therapy early after transplant, including fundoplication, may prove efficacious.

Download full-text


Available from: Eugene H Blackstone, Mar 12, 2014
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Bronchiolitis obliterans syndrome (BOS) is thought to represent chronic allograft rejection. Primary graft dysfunction (PGD), acute cellular rejection (AR), lymphocytic bronchiolitis (LB), abnormal gastroesophageal reflux (GER) with microaspiration, and allograft infection have all been implicated as causes of BOS. Although BOS is generally considered to be caused by alloimmune responses to non-self tissue, more recent findings suggest that autoimmune responses to self-antigens and the triggering of innate immune responses to environment stimuli may play a significant role in the pathobiology of BOS. Effective treatment of BOS remains elusive, but azithromycin may stabilize and possibly improve FEV1 in patients who meet criteria for BOS, and gastric fundoplication may be beneficial if abnormal GER is detected. Augmented immunosuppression is generally ineffective, and other treatments such as total lymphoid irradiation (TLI) or extracorporeal photopheresis (ECP) may not have a significant impact on loss of function. Retransplantation can be considered in carefully selected patients.
    Full-text · Article · Sep 2012
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: For selected parenchymal lung disease patients who fail to respond to medical therapy and demonstrate declines in function that place them at increased risk for mortality, lung transplantation should be considered. Lung transplantation remains a complex medical intervention that requires a dedicated recipient and medical team. Despite the challenges, lung transplantation affords appropriate patients a reasonable chance at increased survival and improved quality of life. Lung transplantation remains an appropriate therapeutic option for selected patients with parenchymal lung disease.
    Preview · Article · Mar 2012 · Clinics in chest medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: This study aimed to evaluate early outcomes after antireflux surgery for lung transplant (LTx) recipients in the United States. Methods: Adult patients undergoing elective antireflux surgery between 2003 and 2008 were identified in the Nationwide Inpatient Sample. A propensity-matched analysis compared early outcomes between prior LTx recipients and well-matched control subjects consisting of non-LTx patients undergoing elective antireflux surgery during the same era. The primary outcome was inpatient mortality, and the secondary outcomes were hospital length of stay (LOS), perioperative complications, and hospital costs. Results: During the study period, 401 LTx recipients underwent elective antireflux surgery. These patients were well matched with 401 control patients in terms of age, sex, individual and overall comorbidity burden, hospital teaching status, hospital location, hospital antireflux volume, and open versus laparoscopic approach. The overall operative mortality rate was 1.4 %, with no difference between the groups. The overall and individual morbidity rates also were similar. The LOS and hospital costs were significantly greater in the LTx group. Multivariable logistic regression analysis confirmed that prior LTx did not confer an increased risk of inpatient mortality after antireflux surgery. Conclusions: To date, this is the largest study to examine outcomes of antireflux surgery for LTx recipients. Operative mortality and morbidity appear to be comparable with those of the general population, although resource utilization is greater. Based on these data, trials to evaluate the role of antireflux surgery in preserving allograft function after LTx should not be hindered by a perceived notion of prohibitive operative risk in this patient population.
    No preview · Article · Dec 2012 · Surgical Endoscopy
Show more