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Vélez C, Neuringer I, Schwarzenberg SJ. The foregut in cystic fibrosis. Pediatr Pulmonol 2024; 59 Suppl 1:S61-S69. [PMID: 39105333 DOI: 10.1002/ppul.27123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 05/23/2024] [Accepted: 06/01/2024] [Indexed: 08/07/2024]
Abstract
The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple "reflux" as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called "GI-related aspiration" or "GRASP." Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomach to the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes-GERD and gastroparesis-that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post-lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF-related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.
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Affiliation(s)
- Christopher Vélez
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Isabel Neuringer
- Division of Pulmonology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Bery AI, Belousova N, Hachem RR, Roux A, Kreisel D. Chronic Lung Allograft Dysfunction: Clinical Manifestations and Immunologic Mechanisms. Transplantation 2024:00007890-990000000-00842. [PMID: 39104003 DOI: 10.1097/tp.0000000000005162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
The term "chronic lung allograft dysfunction" has emerged to describe the clinical syndrome of progressive, largely irreversible dysfunction of pulmonary allografts. This umbrella term comprises 2 major clinical phenotypes: bronchiolitis obliterans syndrome and restrictive allograft syndrome. Here, we discuss the clinical manifestations, diagnostic challenges, and potential therapeutic avenues to address this major barrier to improved long-term outcomes. In addition, we review the immunologic mechanisms thought to propagate each phenotype of chronic lung allograft dysfunction, discuss the various models used to study this process, describe potential therapeutic targets, and identify key unknowns that must be evaluated by future research strategies.
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Affiliation(s)
- Amit I Bery
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Natalia Belousova
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Ramsey R Hachem
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
- Paris Transplant Group, INSERM U970s, Paris, France
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO
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Latorre-Rodríguez AR, Golla M, Arjuna A, Bremner RM, Mittal SK. Impaired esophagogastric junction relaxation and lung transplantation outcomes. Dis Esophagus 2024; 37:doae030. [PMID: 38688726 DOI: 10.1093/dote/doae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/13/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15 mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1 years). The median IRP before and after LTx was 18.7 ± 3.8 mmHg and 12 ± 5.6 mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P = 0.086), but CLAD-free survival (P = 0.592) and rates of primary graft dysfunction (P = 0.502) and acute cellular rejection (P = 0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, D.C., Colombia
| | - Madison Golla
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
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Ramendra R, Duong A, Zhang CYK, Huszti E, Zhou X, Havlin J, Ghany R, Cypel M, Yeung JC, Keshavjee S, Sage AT, Martinu T. Airway pepsinogen A4 identifies lung transplant recipients with microaspiration and predicts chronic lung allograft dysfunction. J Heart Lung Transplant 2024; 43:973-982. [PMID: 38211836 DOI: 10.1016/j.healun.2024.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/04/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant. METHODS Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs. RESULTS PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4. CONCLUSIONS Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Allen Duong
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Xuanzi Zhou
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Alghubari A, Cheah R, Z Shah S, Naser ARN, Lee AS, DeVault KR, Houghton LA. The impact of lung transplantation on esophageal motility and inter-relationships with reflux and lung mechanics in patients with restrictive and obstructive respiratory disease. Neurogastroenterol Motil 2024; 36:e14788. [PMID: 38523356 DOI: 10.1111/nmo.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND For many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed. METHODS We prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33-75 years; 42 men) who underwent high resolution impedance manometry and 24-h pH-impedance before and after LTx. KEY RESULTS RLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post-LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre-LTx (p < 0.001), reducing only in OLD patients' post-LTx (p = 0.02). Reduced EL post-LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco-abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05). CONCLUSIONS AND INFERENCES RLD patients are more likely to show improvement in esophageal motility than OLD patients post-LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration.
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Affiliation(s)
- Ali Alghubari
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Ramsah Cheah
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Sadia Z Shah
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Abdel-Rahman N Naser
- Department of Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Kenneth R DeVault
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Lesley A Houghton
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Elsheikh M, Akanbi L, Selby L, Ismail B. Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls. J Neurogastroenterol Motil 2024; 30:156-165. [PMID: 38062800 PMCID: PMC10999846 DOI: 10.5056/jnm23017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/10/2023] [Accepted: 07/07/2023] [Indexed: 04/06/2024] Open
Abstract
Background/Aims There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls. Methods This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET). Results LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively). Conclusions Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.
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Affiliation(s)
- Mazen Elsheikh
- Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Lekan Akanbi
- Department of Gastroenterology and Hepatology, University of Missouri Health Care, Columbia, MO, USA
| | - Lisbeth Selby
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
| | - Bahaaeldeen Ismail
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
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Jodorkovsky D, Katzka DA, Gyawali CP. A perspective on the clinical relevance of weak or nonacid reflux. Neurogastroenterol Motil 2023; 35:e14671. [PMID: 37702263 DOI: 10.1111/nmo.14671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Advances in ambulatory esophageal reflux monitoring that incorporated impedance electrodes to pH catheters have resulted in better characterization of retrograde bolus flow in the esophagus. With pH-impedance monitoring, in addition to acid reflux episodes identified by pH drops below 4.0, weakly acid reflux (WAR, pH 4-7) and nonacid reflux (NAR, pH >7.0) are also recognized, although both may be included under the umbrella term NAR. However, despite identification of ambulatory pH-impedance monitoring, data on clinical relevance and prognostic value of NAR are limited. The Lyon Consensus, an international expert review that defines conclusive metrics for gastroesophageal reflux disease (GERD), identifies NAR as "supportive" but not conclusive for GERD. PURPOSE This review provides perspectives on whether NAR fulfills three criteria for clinical relevance: whether NAR sufficiently explains pathogenesis of symptoms, whether it is associated with meaningful manifestations of GERD, and whether it can predict treatment efficacy.
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Affiliation(s)
- Daniela Jodorkovsky
- Division of Gastroenterology, Mount Sinai West & Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri, USA
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Bandorski D, Tello K, Erdal H, Sommerlad J, Wilhelm J, Vadasz I, Hecker M, Walmrath D, Seeger W, Krauss E, Kuhnert S. Clinical Utility of Pepsin and Bile Acid in Tracheal Secretions for Accurate Diagnosis of Aspiration in ICU Patients. J Clin Med 2023; 12:5466. [PMID: 37685534 PMCID: PMC10487459 DOI: 10.3390/jcm12175466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Aspiration of stomach content or saliva in critical conditions-e.g., shock, intoxication, or resuscitation-can lead to acute lung injury. While various biomarkers in bronchoalveolar lavage fluids have been studied for diagnosing aspiration, none have been conclusively established as early indicators of lung damage. This study aims to evaluate the diagnostic value of pepsin, bile acid, and other biomarkers for detecting aspiration in an intensive care unit (ICU). MATERIALS AND METHODS In this study, 50 ICU patients were enrolled and underwent intubation before admission. The evaluation of aspiration was based on clinical suspicion or documented instances of observed events. Tracheal secretion (TS) samples were collected within 6 h after intubation using sterile suction catheters. Additional parameters, including IL-6, pepsin, and bile acid, were determined for analysis. Pepsin levels were measured with an ELISA kit, while bile acid, uric acid, glucose, IL-6, and pH value in the tracheal secretion were analyzed using standardized lab methods. RESULTS The 50 patients admitted to the ICU with various diagnoses. The median survival time for the entire cohort was 52 days, and there was no significant difference in survival between patients with aspiration pneumonia (AP) and those with other diagnoses (p = 0.69). Among the AP group, the average survival time was 50.51 days (±8.1 SD; 95% CI 34.63-66.39), while patients with other diagnoses had a mean survival time of 32.86 days (±5.1 SD; 95% CI 22.9-42.81); the survival group comparison did not yield statistically significant results. The presence of pepsin or bile acid in TS patients did not significantly impact survival or the diagnosis of aspiration. The p-values for the correlations between pepsin and bile acid with the aspiration diagnosis were p = 0.53 and p > 0.99, respectively; thus, pepsin and bile acid measurements did not significantly affect survival outcomes or enhance the accuracy of diagnosing aspiration pneumonia. CONCLUSIONS The early and accurate diagnosis of aspiration is crucial for optimal patient care. However, based on this study, pepsin concentration alone may not reliably indicate aspiration, and bile acid levels also show limited association with the diagnosis. Further validation studies are needed to assess the clinical usefulness and reliability of gastric biomarkers in diagnosing aspiration-related conditions. Such future studies would provide valuable insights for improving aspiration diagnosis and enhancing patient care.
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Affiliation(s)
- Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, Lohmühlenstraße 5/Haus P, 20099 Hamburg, Germany
- Intensive Care Medicine and Internal Diagnostics, Neurological Clinic Bad Salzhausen, 63667 Nidda, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
- German Center for Lung Research (DZL), 35392 Giessen, Germany
- The Cardio-Pulmonary Institute (CPI), 35392 Giessen, Germany
- Institute for Lung Health (ILH), 35392 Giessen, Germany
| | - Harun Erdal
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
| | - Janine Sommerlad
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
| | | | - Istvan Vadasz
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
- German Center for Lung Research (DZL), 35392 Giessen, Germany
- The Cardio-Pulmonary Institute (CPI), 35392 Giessen, Germany
- Institute for Lung Health (ILH), 35392 Giessen, Germany
| | - Matthias Hecker
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
- German Center for Lung Research (DZL), 35392 Giessen, Germany
- The Cardio-Pulmonary Institute (CPI), 35392 Giessen, Germany
- Institute for Lung Health (ILH), 35392 Giessen, Germany
| | - Dieter Walmrath
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
- German Center for Lung Research (DZL), 35392 Giessen, Germany
- The Cardio-Pulmonary Institute (CPI), 35392 Giessen, Germany
- Institute for Lung Health (ILH), 35392 Giessen, Germany
- Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, 61231 Bad Nauheim, Germany
| | - Ekaterina Krauss
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
| | - Stefan Kuhnert
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany
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Yang NY, Parish A, Posner S, Shimpi RA, Wood RK, Finn RT, Fisher DA, Hartwig MG, Klapper JA, Reynolds J, Niedzwiecki D, Leiman DA. Acid exposure time is sensitive for detecting gastroesophageal reflux disease and is associated with long-term survival after lung transplant. Dis Esophagus 2023; 36:doac114. [PMID: 36572397 DOI: 10.1093/dote/doac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/27/2022] [Accepted: 12/04/2022] [Indexed: 07/28/2023]
Abstract
Gastroesophageal reflux disease (GERD) is common in patients who have undergone lung transplantation and is associated with poorer outcomes, but guidelines are lacking to direct management strategies in this population. We assessed the diagnostic yield of impedance metrics compared to pH-metry alone for detecting GERD among lung transplant recipients and evaluated their association with clinical outcomes. We performed a retrospective cohort study of consecutive patients who underwent lung transplantation. Demographic data, acid exposure time (AET), number of reflux episodes, mean nocturnal baseline impedance (MNBI), post-reflux swallowing-induced peristaltic wave index (PSPWI), and clinical outcomes including mortality were collected. The relationship between GERD metrics and clinical outcomes was assessed using Wilcoxon signed-rank test and Fisher's exact test as appropriate. Of the 76 patients studied, 29 (38%) had GERD based on abnormal AET after lung transplantation. One (1.3%) patient had GERD based on elevated number of reflux episodes and abnormal distal MNBI detected GERD in 19 (26%) patients, resulting in 62% sensitivity and 94% specificity. Two (2.6%) patients had normal PSPWI. Patients with low distal MNBI had significantly decreased forced expiratory volume in 1 second (FEV1) at 3-year posttransplant compared to those without low distal MNBI (P = 0.03). Three-year survival was significantly worse among patients with elevated AET (66.7% vs. 89.1%, P = 0.03) but not with low distal MNBI (68.4% vs. 84.3%, P = 0.18). Abnormal AET is more sensitive for detecting GERD than other reflux metrics studied and is associated with survival, suggesting pH-metry alone may be sufficient to guide GERD management after lung transplant.
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Affiliation(s)
- Nancy Y Yang
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Shai Posner
- Albany Gastroenterology Consultants, Albany, NY, USA
| | - Rahul A Shimpi
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Richard K Wood
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - R Thomas Finn
- Division of Gastroenterology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John Reynolds
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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10
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Lo WK, Flanagan R, Sharma N, Goldberg HJ, Chan WW. Pre-Lung transplant reflux testing demonstrates high prevalence of gastroesophageal reflux in cystic fibrosis and reduces chronic rejection risk. World J Transplant 2023; 13:138-146. [PMID: 37388387 PMCID: PMC10303416 DOI: 10.5500/wjt.v13.i4.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 03/22/2023] [Accepted: 03/31/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) has been associated with poor outcomes after lung transplantation for chronic lung disease, including increased risk of chronic rejection. GER is common in cystic fibrosis (CF), but factors influencing the likelihood of pre-transplant pH testing, and the impact of testing on clinical management and transplant outcomes in patients with CF are unknown.
AIM To evaluate the role of pre-transplant reflux testing in the evaluation of lung transplant candidates with CF.
METHODS This was a retrospective study from 2007-2019 at a tertiary medical center that included all patients with CF undergoing lung transplant. Patients with pre-transplant anti-reflux surgery were excluded. Baseline characteristics (age at transplantation, gender, race, body mass index), self-reported GER symptoms prior to transplantation, and pre-transplant cardiopulmonary testing results, were recorded. Reflux testing consisted of either 24-h pH- or combined multichannel intraluminal impedance and pH monitoring. Post-transplant care included a standard immunosuppressive regimen, and regular surveillance bronchoscopy and pulmonary spirometry in accordance with institutional practice as well as in symptomatic patients. The primary outcome of chronic lung allograft dysfunction (CLAD) was defined clinically and histologically per International Society of Heart and Lung Transplantation criteria. Statistical analysis was performed with Fisher’s exact test to assess differences between cohorts, and time-to-event Cox proportional hazards modeling.
RESULTS After applying inclusion and exclusion criteria, a total of 60 patients were included in the study. Among all CF patients, 41 (68.3%) completed reflux monitoring as part of pre-lung transplant evaluation. Objective evidence of pathologic reflux, defined as acid exposure time > 4%, was found in 24 subjects, representing 58% of the tested group. CF patients with pre-transplant reflux testing were older (35.8 vs 30.1 years, P = 0.01) and more commonly reported typical esophageal reflux symptoms (53.7% vs 26.3%, P = 0.06) compared to those without reflux testing. Other patient demographics and baseline cardiopulmonary function did not significantly differ between CF subjects with and without pre-transplant reflux testing. Patients with CF were less likely to undergo pre-transplant reflux testing compared to other pulmonary diagnoses (68% vs 85%, P = 0.003). There was a decreased risk of CLAD in patients with CF who underwent reflux testing compared to those who did not, after controlling for confounders (Cox Hazard Ratio 0.26; 95%CI: 0.08-0.92).
CONCLUSION Pre-transplant reflux testing revealed high prevalence of pathologic reflux in CF patients and was associated with decreased risk of CLAD. Systematic reflux testing may enhance outcomes in this patient population.
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Affiliation(s)
- Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Ryan Flanagan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Nirmal Sharma
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
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11
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Frankel A, Kellar T, Zahir F, Chambers D, Hopkins P, Gotley D. Laparoscopic fundoplication after lung transplantation does not appear to alter lung function trajectory. J Heart Lung Transplant 2023; 42:603-609. [PMID: 36609090 DOI: 10.1016/j.healun.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/14/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The primary aim of this study was to determine if allograft function in lung transplant (LTx) recipients improves or stabilizes after laparoscopic fundoplication (LF). The secondary aim was to examine the differences in forced expiratory volume in 1 second (FEV1) before and after LF for various subgroups to identify patients who obtained a superior respiratory outcome after LF, and potential predictive factors for this outcome. METHODS Retrospective analysis of consecutive LTx recipients undergoing LF at a single centre in Brisbane, Australia between 2004 and 2018. 149/431 proceeded to LF after clinical review and pH study. Regular pre- and post-fundoplication pulmonary function tests were collected from participants. Data were analyzed with linear mixed models, random intercept models, the Reliable Change Index (RCI), and graphical and visual analysis of the trajectory of FEV1. RESULTS There was 100% follow-up. After Bonferroni adjustment for multiple comparison was performed, none of the models demonstrated statistical significance. The Reliable Change Index showed one patient had a significant improvement in lung function across that time period, while nine had a significant reduction. The rate of change before and after LF was similar for the 132/149 patients for whom the first and last pre- and post-LF FEV1 values were available. A subset of patients had a considerable reduction in their FEV1 in the peri-operative period (i.e., a large difference between the first measurement post-LF and the final measurement pre-LF). CONCLUSION In the largest published cohort to date, LF performed in a high-volume center did not appear to alter the reduction in allograft function seen with time.
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Affiliation(s)
- Adam Frankel
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, The University of Queensland, Herston Queensland, Australia.
| | - Trina Kellar
- The Prince Charles Hospital, Chermside Queensland, Australia
| | - Farah Zahir
- QCIF Facility for Advanced Bioinformatics, Woolloongabba, Queensland, Australia
| | - Daniel Chambers
- Faculty of Medicine, The University of Queensland, Herston Queensland, Australia; The Prince Charles Hospital, Chermside Queensland, Australia
| | - Peter Hopkins
- Faculty of Medicine, The University of Queensland, Herston Queensland, Australia; The Prince Charles Hospital, Chermside Queensland, Australia
| | - David Gotley
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, The University of Queensland, Herston Queensland, Australia
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12
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Halitim P, Tissot A. [Chronic lung allograft dysfunction in 2022, past and updates]. Rev Mal Respir 2023; 40:324-334. [PMID: 36858879 DOI: 10.1016/j.rmr.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION While short-term results of lung transplantation have improved considerably, long-term survival remains below that achieved for other solid organ transplants. CURRENT KNOWLEDGE The main cause of late mortality is chronic lung allograft dysfunction (CLAD), which affects nearly half of the recipients 5 years after transplantation. Immunological and non-immune risk factors have been identified. These factors activate the innate and adaptive immune system, leading to lesional and altered wound-healing processes, which result in fibrosis affecting the small airways or interstitial tissue. Several phenotypes of CLAD have been identified based on respiratory function and imaging pattern. Aside from retransplantation, which is possible for only small number of patients, no treatment can reverse the CLAD process. PERSPECTIVES Current therapeutic research is focused on anti-fibrotic treatments and photopheresis. Basic research has identified numerous biomarkers that could prove to be relevant as therapeutic targets. CONCLUSION While the pathophysiological mechanisms of CLAD are better understood than before, a major therapeutic challenge remains.
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Affiliation(s)
- P Halitim
- Service de pneumologie et soins intensifs, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France; Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France
| | - A Tissot
- Service de pneumologie, CHU de Nantes, l'Institut du thorax, Nantes Université, Inserm, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44093 Nantes cedex, France.
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13
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Razia D, Mittal SK, Bansal S, Ravichandran R, Giulini L, Smith MA, Walia R, Mohanakumar T, Bremner RM. Association Between Antibodies Against Lung Self-Antigens and Gastroesophageal Reflux in Lung Transplant Candidates. Semin Thorac Cardiovasc Surg 2023; 35:177-186. [PMID: 35181441 DOI: 10.1053/j.semtcvs.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/09/2022] [Indexed: 11/11/2022]
Abstract
Gastroesophageal reflux (GER) and pretransplant antibodies against lung self-antigens (SAbs) collagen-V and/or k-alpha 1 tubulin are both independently associated with allograft dysfunction after lung transplantation (LTx). The role of GER in inducing lung injury and SAbs is unknown. We aimed to study the association between pre-LTx GER and SAbs. After IRB approval, we retrieved SAb assays conducted between 2015 and 2019 and collected 24 hour GER data for these patients. Patients were divided into 2 groups: no reflux (GER-) and pathologic reflux (GER+) to compare the prevalence of SAbs. Multivariate analysis was used to study the association between GER and SAbs in the whole cohort and in restrictive lung disease (RLD) and obstructive lung disease (OLD) subsets. Proximal esophageal reflux (PER) events ≥5 was considered abnormal. Patients (n = 134; 73 men) were divided into groups: GER- (54.5%, n = 73) and GER+ (45.5%, n = 61). The prevalence of GER was higher in the RLD than in the OLD subset (p < 0.001). The overall prevalence of SAbs was 53.7% (n = 72), higher in the GER+ than the GER- group (65.6% vs 43.8%, p = 0.012), but comparable between RLD and OLD subsets. Overall, SAbs were associated with GER (p = 0.012) and abnormal PER (p = 0.017). GER and abnormal PER increased the odds of SAbs in the RLD subset (OR [95% CI]: 2.825 [1.033-7.725], p = 0.040 and OR [95% CI]: 3.551 [1.271-9.925], p = 0.014, respectively) but not in the OLD subset. LTx candidates have a high prevalence of SAbs, which are significantly associated with GER and abnormal PER in patients with RLD.
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Affiliation(s)
- Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona.
| | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Thalachallour Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 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, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
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14
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Johnston N, Samuels TL, Goetz CJ, Arnold LA, Smith BC, Seabloom D, Wuertz B, Ondrey F, Wiedmann TS, Vuksanovic N, Silvaggi NR, MacKinnon AC, Miller J, Bock J, Blumin JH. Oral and Inhaled Fosamprenavir Reverses Pepsin-Induced Damage in a Laryngopharyngeal Reflux Mouse Model. Laryngoscope 2023; 133 Suppl 1:S1-S11. [PMID: 35678265 PMCID: PMC9732152 DOI: 10.1002/lary.30242] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE More than 20% of the US population suffers from laryngopharyngeal reflux. Although dietary/lifestyle modifications and alginates provide benefit to some, there is no gold standard medical therapy. Increasing evidence suggests that pepsin is partly, if not wholly, responsible for damage and inflammation caused by laryngopharyngeal reflux. A treatment specifically targeting pepsin would be amenable to local, inhaled delivery, and could prove effective for endoscopic signs and symptoms associated with nonacid reflux. The aim herein was to identify small molecule inhibitors of pepsin and test their efficacy to prevent pepsin-mediated laryngeal damage in vivo. METHODS Drug and pepsin binding and inhibition were screened by high-throughput assays and crystallography. A mouse model of laryngopharyngeal reflux (mechanical laryngeal injury once weekly for 2 weeks and pH 7 solvent/pepsin instillation 3 days/week for 4 weeks) was provided inhibitor by gavage or aerosol (fosamprenavir or darunavir; 5 days/week for 4 weeks; n = 3). Larynges were collected for histopathologic analysis. RESULTS HIV protease inhibitors amprenavir, ritonavir, saquinavir, and darunavir bound and inhibited pepsin with IC50 in the low micromolar range. Gavage and aerosol fosamprenavir prevented pepsin-mediated laryngeal damage (i.e., reactive epithelia, increased intraepithelial inflammatory cells, and cell apoptosis). Darunavir gavage elicited mild reactivity and no discernable protection; aerosol protected against apoptosis. CONCLUSIONS Fosamprenavir and darunavir, FDA-approved therapies for HIV/AIDS, bind and inhibit pepsin, abrogating pepsin-mediated laryngeal damage in a laryngopharyngeal reflux mouse model. These drugs target a foreign virus, making them ideal to repurpose. Reformulation for local inhaled delivery could further improve outcomes and limit side effects. LEVEL OF EVIDENCE NA. Laryngoscope, 133:S1-S11, 2023.
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Affiliation(s)
- Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
- Department of Microbiology and Immunology, Medical College of Wisconsin
| | - Tina L. Samuels
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
| | | | - Leggy A. Arnold
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin, Milwaukee, WI
| | - Brian C. Smith
- Department of Biochemistry, Medical College of Wisconsin
| | - Donna Seabloom
- Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | - Beverly Wuertz
- Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | - Frank Ondrey
- Department of Otolaryngology Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | | | - Nemanja Vuksanovic
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin, Milwaukee, WI
| | - Nicholas R. Silvaggi
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin, Milwaukee, WI
| | | | - James Miller
- Department of Pathology, Medical College of Wisconsin
| | - Jonathan Bock
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Joel H. Blumin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI
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15
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McGinniss JE, Whiteside SA, Deek RA, Simon-Soro A, Graham-Wooten J, Oyster M, Brown MD, Cantu E, Diamond JM, Li H, Christie JD, Bushman FD, Collman RG. The Lung Allograft Microbiome Associates with Pepsin, Inflammation, and Primary Graft Dysfunction. Am J Respir Crit Care Med 2022; 206:1508-1521. [PMID: 36103583 PMCID: PMC9757091 DOI: 10.1164/rccm.202112-2786oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 09/14/2022] [Indexed: 12/24/2022] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the principal cause of early morbidity and mortality after lung transplantation. The lung microbiome has been implicated in later transplantation outcomes but has not been investigated in PGD. Objectives: To define the peritransplant bacterial lung microbiome and relationship to host response and PGD. Methods: This was a single-center prospective cohort study. Airway lavage samples from donor lungs before organ procurement and recipient allografts immediately after implantation underwent bacterial 16S ribosomal ribonucleic acid gene sequencing. Recipient allograft samples were analyzed for cytokines by multiplex array and pepsin by ELISA. Measurements and Main Results: We enrolled 139 transplant subjects and obtained donor lung (n = 109) and recipient allograft (n = 136) samples. Severe PGD (persistent grade 3) developed in 15 subjects over the first 72 hours, and 40 remained without PGD (persistent grade 0). The microbiome of donor lungs differed from healthy lungs, and recipient allograft microbiomes differed from donor lungs. Development of severe PGD was associated with enrichment in the immediate postimplantation lung of oropharyngeal anaerobic taxa, particularly Prevotella. Elevated pepsin, a gastric biomarker, and a hyperinflammatory cytokine profile were present in recipient allografts in severe PGD and strongly correlated with microbiome composition. Together, immediate postimplantation allograft Prevotella/Streptococcus ratio, pepsin, and indicator cytokines were associated with development of severe PGD during the 72-hour post-transplantation period (area under the curve = 0.81). Conclusions: Lung allografts that develop PGD have a microbiome enriched in anaerobic oropharyngeal taxa, elevated gastric pepsin, and hyperinflammatory phenotype. These findings suggest a possible role for peritransplant aspiration in PGD, a potentially actionable mechanism that warrants further investigation.
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Affiliation(s)
- John E. McGinniss
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | | | - Aurea Simon-Soro
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Melanie D. Brown
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | - Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Hongzhe Li
- Department of Epidemiology, Biostatistics, and Informatics
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Frederic D. Bushman
- Department of Microbiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronald G. Collman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Microbiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Routine Reflux Testing Guides Timely Antireflux Treatment to Reduce Acute and Chronic Rejection After Lung Transplantation. Clin Transl Gastroenterol 2022; 14:e00538. [PMID: 36201668 PMCID: PMC9875950 DOI: 10.14309/ctg.0000000000000538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/23/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Gastroesophageal reflux has been associated with poorer lung transplantation outcomes, although no standard approach to evaluation/management has been adopted. We aimed to evaluate the effect of timely antireflux treatment as guided by routine reflux testing on postlung transplant rejection outcomes. METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary center. All patients underwent pretransplant ambulatory pH monitoring. Timely antireflux treatment was defined as proton pump inhibitor initiation or antireflux surgery within 6 months of transplantation. Patients were separated into 3 groups: normal pH monitoring (-pH), increased reflux (+pH) with timely treatment, and +pH with delayed treatment. Rejection outcomes included acute rejection, bronchiolitis obliterans syndrome, and chronic lung allograft dysfunction per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses using Cox proportional hazard models were applied. Patients not meeting outcomes were censored at death or last clinic visit. RESULTS One hundred seventy-five patients (59% men/mean 56.3 yr/follow-up: 496 person-years) were included. On multivariable analyses, +pH/delayed treatment patients had higher risks of acute rejection (adjust hazard ratio [aHR]:3.81 [95% confidence interval [CI]: 1.90-7.64], P = 0.0002), bronchiolitis obliterans syndrome (aHR: 2.22 [95% CI: 1.07-4.58], P = 0.03), and chronic lung allograft dysfunction (aHR: 2.97 [95% CI: 1.40-6.32], P = 0.005) than +pH/timely treatment patients. Similarly, rejection risks were increased among +pH/delayed treatment patients vs -pH patients (all P < 0.05). No significant differences in rejection risks were noted between +pH/timely treatment patients and -pH patients. Failure/complications of antireflux treatment were rare and similar among groups. DISCUSSION Timely antireflux treatment, as directed by pretransplant reflux testing, was associated with reduced allograft rejection risks and demonstrated noninferiority to patients without reflux. A standardized peri-transplant test-and-treat algorithm may guide timely reflux management to improve lung transplant outcomes.
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17
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Outcomes of partial fundoplication for GERD-related allograft decline after lung transplantation. Surg Endosc 2022; 37:3963-3967. [PMID: 36001153 DOI: 10.1007/s00464-022-09529-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/31/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease contributes to allograft decline secondary to bronchiolitis obliterans after lung transplantation. Antireflux surgery (ARS) slows the decline in lung function related to GERD. ARS operations range from Nissen fundoplications to partial fundoplications, such as the Toupet and Dor. Research in the general population has indicated that partial fundoplication is effective at controlling reflux. We explored lung function and reflux outcomes in a cohort of lung transplant patients who received partial fundoplications. METHODS Data from an institutional lung transplant registry was reviewed for patients between 2009 and 2020 who underwent fundoplication after transplant. Lung transplant patients underwent routine pulmonary function testing. Patients with FEV1 values within 180 days pre-fundoplication and two years post-fundoplication were included in the analysis. All patients referred for fundoplication underwent esophageal pH testing, manometry, UGI, and EGD. Most patients underwent Toupet fundoplication, but those with severe dysmotility underwent Dor fundoplication. RESULTS 53 patients were included in the analysis. Median time to fundoplication after transplant was 403 days. 48 patients underwent Toupet fundoplication. Five underwent Dor fundoplication. 40% of patients had abnormal high-resolution manometry. A linear mixed-effects model tested for a change in FEV1 trajectory up to two years post-fundoplication with an auto-regressive correlation structure. Post-fundoplication FEV1 values decreased by 7 mL per month, and suggested a slow in the decline by 2 mL per month, but this was not significant (p = 0.8). In patients for whom postoperative DeMeester scores were available (19), there was a decline in acid exposure from a median of 45.8 to 1.8 after ARS (p = 0.0003). CONCLUSION Although our results did not reach statistical significance, there was a trend towards a decrease in the rate of decline of allograft function before and after partial fundoplication. In the patients whom results were available, a partial fundoplication appropriately controlled acid exposure.
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18
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Pepsin and the Lung—Exploring the Relationship between Micro-Aspiration and Respiratory Manifestations of Gastroesophageal Reflux Disease. J Pers Med 2022; 12:jpm12081296. [PMID: 36013245 PMCID: PMC9410290 DOI: 10.3390/jpm12081296] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered disorders in clinical practice nowadays, with an increasing burden on healthcare systems worldwide. GERD-related respiratory symptoms such as unexplained chronic cough, bronchial asthma or chronic obstructive pulmonary disease (COPD) with frequent exacerbations often pose diagnostic and therapeutic challenges and may require a multidisciplinary approach. Moreover, a potential role of GERD as a risk factor has been proposed for chronic rejection in patients who underwent lung transplantation. Pepsin has gained considerable attention from the scientific community in the last few years as a possible surrogate biomarker for GERD. The aim of this narrative review was to provide an overview of the potential utility of pepsin detection as a marker of micro-aspiration in various biological fluids retrieved from patients with suspected GERD-induced respiratory manifestations and in lung transplant patients with allograft dysfunction. Data on the subject remains highly contradictory, and while certain studies support its applicability in investigating atypical GERD manifestations, at the moment, it would be realistic to accept a modest utility at best. A major lack of consensus persists regarding topics such as the optimal timeframe for fluid collection and cut-off values. Further research is warranted in order to address these issues.
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19
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Son J, Shin C. Indications for Lung Transplantation and Patient Selection. J Chest Surg 2022; 55:255-264. [PMID: 35924530 PMCID: PMC9358156 DOI: 10.5090/jcs.22.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Globally, thousands of patients undergo lung transplantation owing to end-stage lung disease each year. As lung transplantation evolves, recommendations and indications are constantly being updated. In 2021, the International Society for Heart and Lung Transplantation published a new consensus document for selecting candidates for lung transplantation. However, it is still difficult to determine appropriate candidates for lung transplantation among patients with complex medical conditions and various diseases. Therefore, it is necessary to analyze each patient’s overall situation and medical condition from various perspectives, and ongoing efforts to optimize the analysis will be necessary. The purpose of this study is to review the extant literature and discuss recent updates.
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Affiliation(s)
- Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Changwon Shin
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
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20
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Hashemi-Bajgani SM, Samareh-Fekri M, Paghaleh AJ, Yazdani R, Zarandi MA, Shafahi A. Prevalence of Micro-Aspiration of Bile Acids in Patients with Primary Lung Cancer: A Cross-Sectional Study. Ethiop J Health Sci 2022; 32:715-722. [PMID: 35950065 PMCID: PMC9341028 DOI: 10.4314/ejhs.v32i4.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Lung cancer remains a serious public health problem and is the first cause of cancer-related death worldwide. There is some evidence suggests that bile acid micro-aspiration may contribute to the development of lung diseases. This study aimed to assess the prevalence of micro-aspiration of bile acids in patients with primary lung cancer. Methods In a cross-sectional study, 52 patients with primary lung cancer referred to a teaching hospital affiliated with Kerman University of Medical Sciences, Kerman, Iran were enrolled. Patients with pathology-confirmed lung cancer who did not receive specific treatment were included in the present study. All patients underwent bronchoscopy and the levels of bile acid was assessed in their Broncho-Alveolar Lavage (BAL) samples. Results According to the results, 53.85% of patients were in the age group of 40 to 59 years. Of the participants, 88.46% were male, 82.69% were smokers, and 69.23% were opium addicted. The most common presenting clinical symptoms of patients were heartburn (61.55%), hoarseness (17.31%), and epigastric pain (9.61%), respectively. Ninety-two point thirty-two percent of patients had endobronchial lesions in bronchoscopy. Squamous cell carcinoma, small-cell lung carcinoma and adenocarcinoma accounts for 48.08%, 34.61% and 17.31% of all cases of lung cancer, respectively. Bile acids were found in the BAL sample of all patients with primary lung cancer. The mean Bile acids levels in patients were 63.42 (SD=7.03) µmol/Lit. Conclusion According to the results of present study, there was a micro-aspiration of bile acids in all patients with primary lung cancer that may participate in shaping early events in the etiology of primary lung cancer. It seems that developing clinical strategies preventing the micro-aspiration of bile acids into the lungs could remove a key potential trigger in this process.
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Affiliation(s)
| | - Mitra Samareh-Fekri
- Cardiovascular Research Center, Basic and Clinical Institute of Physiology, Kerman University of Medical Sciences, Kerman, Iran
| | - Arshia Jamali Paghaleh
- Afzalipour Hospital Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Rostam Yazdani
- Afzalipour Hospital Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahboobe Asadi Zarandi
- Afzalipour Hospital Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Shafahi
- Afzalipour Hospital Research Center, Kerman University of Medical Sciences, Kerman, Iran
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Glanville AR, Benden C, Bergeron A, Cheng GS, Gottlieb J, Lease ED, Perch M, Todd JL, Williams KM, Verleden GM. Bronchiolitis obliterans syndrome after lung or haematopoietic stem cell transplantation: current management and future directions. ERJ Open Res 2022; 8:00185-2022. [PMID: 35898810 PMCID: PMC9309343 DOI: 10.1183/23120541.00185-2022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) may develop after either lung or haematopoietic stem cell transplantation (HSCT), with similarities in histopathological features and clinical manifestations. However, there are differences in the contributory factors and clinical trajectories between the two conditions. BOS after HSCT occurs due to systemic graft-versus-host-disease (GVHD), whereas BOS after lung transplantation is limited to the lung allograft. BOS diagnosis after HSCT is more challenging, as the lung function decline may occur due to extrapulmonary GVHD, causing sclerosis or inflammation in the fascia or muscles of the respiratory girdle. Treatment is generally empirical with no established effective therapies. This review provides rare insights and commonalities of both conditions, that are not well elaborated elsewhere in contemporary literature, and highlights the importance of cross disciplinary learning from experts in other transplant modalities. Treatment algorithms for each condition are presented, based on the published literature and consensus clinical opinion. Immunosuppression should be optimised, and other conditions or contributory factors treated where possible. When initial treatment fails, the ultimate therapeutic option is lung transplantation (or re-transplantation in the case of BOS after lung transplantation) in carefully selected candidates. Novel therapies under investigation include aerosolised liposomal cyclosporine, Janus kinase inhibitors, antifibrotic therapies, and (in patients with BOS after lung transplantation) B-cell–directed therapies. Effective novel treatments that have a tangible impact on survival and thereby avoid the need for lung transplantation or re-transplantation are urgently required.
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De Luca D, Alonso A, Autilio C. Bile acids-induced lung injury: update of reverse translational biology. Am J Physiol Lung Cell Mol Physiol 2022; 323:L93-L106. [DOI: 10.1152/ajplung.00523.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The presence of bile acids in lung tissue is associated with some clinical features observed in various medical specialties, but it took time to understand that these are due to a "bile acid-induced lung injury" since specific translational studies and cross-disciplinary awareness were lacking. We used a reverse translational approach to update and summarize the current knowledge about the mechanisms of bile acid-induced lung injury. This has been done in a cross-disciplinary fashion since these conditions may occur in patients of various age and in different medical fields. We here define these clinical conditions, then we review the physiopathology of these conditions and the animal models used to mimic them and, finally, their pathobiology. Mechanisms of bile acid-induced lung injury have been partially clarified overtime and are represented by: 1) the interaction with secretory phospholipase A2 pathway, 2) the effect on surfactant function and structure, 3) the biological effects on inflammation and local immunity, 4) the direct cellular toxicity. These mechanisms are schematically illustrated and histological comparisons between ARDS induced by bile acids and other triggers are also provided. Based on these mechanisms we propose possible direct therapeutic applications and, finally, we discuss further research steps to improve the understanding of processes that generate pathological clinical conditions.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Paris Saclay University Hospital, Clamart, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Le Plessis Robinson, France
| | - Alejandro Alonso
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research, Institut-Hospital, Complutense University, Madrid, Spain
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research, Institut-Hospital, Complutense University, Madrid, Spain
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Ichkhanian Y, Hwang JH, Ofosu A, Li AA, Szvarca D, Draganov PV, Yang D, Alsheik E, Zuchelli T, Piraka C, Mony S, Khashab MA. Role of gastric per-oral endoscopic myotomy (G-POEM) in post-lung transplant patients: a multicenter experience. Endosc Int Open 2022; 10:E832-E839. [PMID: 35692909 PMCID: PMC9187381 DOI: 10.1055/a-1797-9587] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Background and study aims Gastroparesis post-lung transplant (LTx) can lead to increased risk of gastroesophageal reflux (GER) and accelerated graft dysfunction. We aimed to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM), a promising tool in patients with refractory gastroparesis, for managing refractory gastroparesis and GER in post-LTx patients. Patents and methods This was a multicenter retrospective study on post-LTx patients who underwent G-POEM for management of gastroparesis and GER that were refractory to standard medical therapy. The primary outcome was clinical success post-G-POEM. Secondary outcomes included the rate of post-G-POEM objective esophageal pH exam normalization, rate of gastric emptying scintigraphy (GES) normalization, technical success, and adverse events. Results A total of 20 patients (mean age 54.7 ± 14.1 years, Female 50 %) underwent G-POEM at a median time of 13 months (interquartile range 6.5-13.5) post-LTx. All G-POEM procedures were technically successful. Clinical success was achieved in 17 (85 %) patients during a median follow-up time of 8.9 (IQR: 3-17) months post-G-POEM. Overall GCSI and two of its subscales (bloating and postprandial fullness/early satiety) improved significantly following G-POEM. Two patients (10 %) developed post-procedural AEs (delayed bleeding 1, pyloric stenosis 1, both moderate in severity). Post-G-POEM GES improvement was achieved in 12 of 16 patients (75 %). All 20 patients were on proton pump inhibitors pre-G-POEM, as opposed to five post-G-POEM. Post-G-POEM PH study normalization was noted in nine of 10 patients (90 %) who underwent both pre- and post-G-poem pH testing. Conclusions G-POEM is a promising noninvasive therapeutic tool for management of refractory gastroparesis and GER post-LTx.
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Affiliation(s)
- Yervant Ichkhanian
- Henry Ford Health System, Department of Internal Medicine, Detroit, Michigan, United States
| | - Joo Ha Hwang
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Andrew Ofosu
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Andrew A Li
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Daniel Szvarca
- Johns Hopkins Hospital, Department of Internal Medicine, Baltimore, Maryland, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Eva Alsheik
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Tobias Zuchelli
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Cyrus Piraka
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Shruti Mony
- Johns Hopkins Hospital, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Johns Hopkins Hospital, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
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Trinh BN, Brzezinski M, Kukreja J. Early Postoperative Management of Lung Transplant Recipients. Thorac Surg Clin 2022; 32:185-195. [PMID: 35512937 DOI: 10.1016/j.thorsurg.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The early postoperative period after lung transplantation is a critical time. Prompt recognition and treatment of primary graft dysfunction can alter long-term allograft function. Cardiovascular, gastrointestinal, renal, and hematologic derangements are common and require close management to limit their negative sequelae.
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Affiliation(s)
- Binh N Trinh
- Division of Cardiothoracic Surgery, University of California, San Francisco, 500 Parnassus Avenue, Suite MUW-405, San Francisco, CA 94143-0118, USA
| | - Marek Brzezinski
- Department of Anesthesia, University of California, San Francisco, 500 Parnassus Avenue, Suite MUW-405, San Francisco, CA 94143-0118, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, University of California, San Francisco, 500 Parnassus Avenue, Suite MUW-405, San Francisco, CA 94143-0118, USA.
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25
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Bedair B, Hachem RR. Management of chronic rejection after lung transplantation. J Thorac Dis 2022; 13:6645-6653. [PMID: 34992842 PMCID: PMC8662511 DOI: 10.21037/jtd-2021-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/20/2021] [Indexed: 12/17/2022]
Abstract
Outcomes after lung transplantation are limited by chronic lung allograft dysfunction (CLAD). The incidence of CLAD is high, and its clinical course tends to be progressive over time, culminating in graft failure and death. Indeed, CLAD is the leading cause of death beyond the first year after lung transplantation. Therapy for CLAD has been limited by a lack of high-quality studies to guide management. In this review, we will discuss the diagnosis of CLAD in light of the recent changes to definitions and will discuss the current clinical evidence available for treatment. Recently, the diagnosis of CLAD has been subdivided into bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). The current evidence for treatment of CLAD mainly revolves around treatment of BOS with more limited data existing for RAS. The best supported treatment to date for CLAD is the macrolide antibiotic azithromycin which has been associated with a small improvement in lung function in a minority of patients. Other therapies that have more limited data include switching immunosuppression from cyclosporine to tacrolimus, fundoplication for gastroesophageal reflux, montelukast, extracorporeal photopheresis (ECP), aerosolized cyclosporine, cytolytic anti-lymphocyte therapies, total lymphoid irradiation (TLI) and the antifibrotic agent pirfenidone. Most of these treatments are supported by case series and observational studies. Finally, we will discuss the role of retransplantation for CLAD.
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Affiliation(s)
- Bahaa Bedair
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, MO 63110, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, MO 63110, USA
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Rosen R, Lurie M, Kane M, DiFilippo C, Cohen A, Freiberger D, Boyer D, Visner G, Narvaez-Rivas M, Liu E, Setchell K. Risk Factors for Bile Aspiration and its Impact on Clinical Outcomes. Clin Transl Gastroenterol 2021; 12:e00434. [PMID: 34978997 PMCID: PMC8893291 DOI: 10.14309/ctg.0000000000000434] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Bile reflux may cause for lung allograft rejection, yet there are no studies that determine (i) the relationship between gastric and lung bile concentrations, (ii) whether bile is present in lungs of nontransplant patients, (iii) the relationship between gastric dysmotility and lung bile, (iv) the impact of reflux therapies on lung bile, and (v) whether lung bile worsens outcomes in nontransplant patients. This study will address these gaps in the literature. METHODS We prospectively recruited lung transplant (LTX) patients and nontransplant patients with respiratory symptoms (RP) and collected paired gastric and lung samples. Bile concentration and composition of samples was assessed using liquid chromatography-mass spectrometry. Bile results were compared with clinical parameters, including the presence of esophagitis, gastric dysmotility, and/or pathologic gastroesophageal reflux. RESULTS Seventy patients (48 RP and 22 LTX) were recruited. Overall, 100% of gastric and 98% of bronchoalveolar lavage samples contained bile. The mean gastric bile concentrations in RP and LTX patients were 280 ± 703 nmol/L and 1,004 ± 1721 nmol/L, respectively (P = 0.02). There was no difference in lung bile concentrations between RP (9 ± 30 nmol/L) and LTX (11 ± 15 nmol/L, P = 0.7). Patients with delayed gastric emptying had higher lung bile concentrations (15.5 ± 18.8 nmol/L) than patients with normal gastric emptying (4.8 ± 5.7 nmol/L, P = 0.05) independently of reflux burden. Proton pump inhibitor use increased the proportion of unconjugated gastric bile acids. High lung bile concentrations were associated with an increased risk of hospitalization and longer hospital stays in RP patients (P < 0.05). DISCUSSION Lung bile is almost universally present in symptomatic patients, and higher concentrations are associated with poorer respiratory outcomes.
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Affiliation(s)
- Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margot Lurie
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Madeline Kane
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Courtney DiFilippo
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexandra Cohen
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dawn Freiberger
- Pediatric Lung Transplant Program, Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Debra Boyer
- Pediatric Lung Transplant Program, Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gary Visner
- Pediatric Lung Transplant Program, Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica Narvaez-Rivas
- Division of Gastroenterology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kenneth Setchell
- Division of Gastroenterology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
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Abstract
The aim of this review is to explore the relationship between esophageal syndromes and pulmonary diseases considering the most recent data available. Prior studies have shown a close relationship between lung diseases such as asthma, chronic obstructive pulmonary disorders (COPD), Idiopathic pulmonary fibrosis (IPF), and lung transplant rejection and esophageal dysfunction. Although the association has long been demonstrated, the exact relationship remains unclear. Clinical experience has shown a bidirectional relationship where esophageal disease may influence the outcomes of pulmonary disease and vice versa. The impact of esophageal dysfunction on pulmonary disorders may also be related to 2 different mechanisms: the reflux pathway leading to microaspiration and the reflex pathway triggering vagally mediated airway reactions. The aim of this review is to further explore these relationships and pathophysiologic mechanisms. Specifically, we discuss the proposed hypotheses for the relationship between the 2 diseases, as well as the pathophysiology and new developments in clinical management.
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28
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Khoma O, Park JS, Lee FM, Van der Wall H, Falk GL. Different clinical symptom patterns in patients with reflux micro-aspiration. ERJ Open Res 2021; 8:00508-2021. [PMID: 35083320 PMCID: PMC8784889 DOI: 10.1183/23120541.00508-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background Pulmonary manifestation of gastro-oesophageal reflux disease (GORD) is a well-recognised entity; however, little primary reported data exists on presenting symptoms of patients in whom reflux micro-aspiration is confirmed. The aim of this study is to report symptoms and presenting patterns of a large group of patients with confirmed reflux micro-aspiration. Patients and methods Data was extracted from a prospectively populated database of patients referred to a tertiary specialist centre with severe, refractory or atypical reflux. Patients with reflux micro-aspiration on scintigraphy were included in this study. A separate group included patients with evidence of proximal reflux to the level of pharynx when supine and/or upright. Results Inclusion criteria were met by 243 patients with confirmed reflux micro-aspiration (33% males; mean age 59). Most common symptoms amongst patients with micro-aspiration were regurgitation (72%), cough (67%), heartburn (66%), throat clearing (65%) and dysphonia (53%). The most common two-symptom combinations were heartburn/regurgitation, cough/throat clearing, regurgitation/throat clearing, cough/regurgitation and dysphonia/throat clearing. The most common three-symptom combinations were cough/heartburn/regurgitation, cough/regurgitation/throat clearing and dysphonia/regurgitation/throat clearing. Cluster analysis demonstrated two main symptom groupings, one suggestive of proximal volume reflux symptoms and the other with motility/inflammatory bowel syndrome-like symptoms (bloat, constipation). Conclusion The combination of typical symptoms of GORD such as heartburn or regurgitation and a respiratory or upper aero-digestive complaint such as cough, throat clearing or voice change should prompt consideration of reflux micro-aspiration. Patients with reflux micro-aspiration most commonly present with a combination of regurgitation and/or heartburn and cough and/or throat clearinghttps://bit.ly/3GM8cNS
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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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Leiva-Juarez MM, Benvenuto L, Costa J, Blackett JW, Aversa M, Robbins H, Shah L, Stanifer BP, Lemaître PH, Jodorkovsky D, Arcasoy S, Sonett JR, D'Ovidio F. Identification of Lung Transplant Recipients with a Survival Benefit after Fundoplication. Ann Thorac Surg 2021; 113:1801-1810. [PMID: 34280376 DOI: 10.1016/j.athoracsur.2021.05.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/02/2021] [Accepted: 05/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) and aspiration of enteric contents is associated with worse outcomes after lung transplant. The purpose of this study is to elucidate populations that benefit the most from fundoplication after lung transplant. METHODS Lung transplants from 2001-2019 (n=971) were retrospectively reviewed and stratified by a fundoplication before (n=128) or after (n=24) chronic lung allograft dysfunction (CLAD) development vs those who didn't. Patients with a fundoplication prior to CLAD were propensity-matched to those without a fundoplication. The primary outcome of interest was post-transplant survival. Time-to-event rates were calculated using a multivariable Cox proportional hazards model and Kaplan-Meier functions. RESULTS A fundoplication prior to CLAD improved post-transplant survival before and after propensity-matching, and remained a significant predictor after adjusting for baseline characteristics (HR:0.57, 95% CI:0.4-0.8, P=0.001). Recipients with a restrictive disorder (HR: 0.46, 95% CI:0.3-0.73, P=0.001), age <65 (HR:0.48, 95% CI:0.32-0.71, P<0.001), and both single (HR:0.47, 95% CI:0.28-0.79, P=0.005) or double (HR:0.55, 95% CI:0.32-0.93, P=0.027) lung transplants had a significant decrease in mortality after fundoplication. The effect was present after excluding early deaths and/or CLAD diagnoses. GERD diagnosed by pH, impedance or EGD was not associated with worse outcomes. Among patients with CLAD, a fundoplication was an independent predictor of post-CLAD survival (HR:0.27, 95% CI:0.12-0.61, P=0.002). CONCLUSIONS A fundoplication before or after CLAD development is an independent predictor of survival. Younger patients with restrictive disease, independent of the type of transplant, have a survival benefit. GERD diagnosed by conventional methods was not associated with worse survival.
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Affiliation(s)
- Miguel M Leiva-Juarez
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joseph Costa
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - John W Blackett
- Division of Gastroenterology, Columbia University Medical Center, New York, New York
| | - Meghan Aversa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Hilary Robbins
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Lori Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Bryan P Stanifer
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Phillippe H Lemaître
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Daniela Jodorkovsky
- Division of Gastroenterology, Columbia University Medical Center, New York, New York
| | - Selim Arcasoy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joshua R Sonett
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Frank D'Ovidio
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York.
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Systems Biology and Bile Acid Signalling in Microbiome-Host Interactions in the Cystic Fibrosis Lung. Antibiotics (Basel) 2021; 10:antibiotics10070766. [PMID: 34202495 PMCID: PMC8300688 DOI: 10.3390/antibiotics10070766] [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: 05/11/2021] [Revised: 06/14/2021] [Accepted: 06/21/2021] [Indexed: 12/16/2022] Open
Abstract
The study of the respiratory microbiota has revealed that the lungs of healthy and diseased individuals harbour distinct microbial communities. Imbalances in these communities can contribute to the pathogenesis of lung disease. How these imbalances occur and establish is largely unknown. This review is focused on the genetically inherited condition of Cystic Fibrosis (CF). Understanding the microbial and host-related factors that govern the establishment of chronic CF lung inflammation and pathogen colonisation is essential. Specifically, dissecting the interplay in the inflammation–pathogen–host axis. Bile acids are important host derived and microbially modified signal molecules that have been detected in CF lungs. These bile acids are associated with inflammation and restructuring of the lung microbiota linked to chronicity. This community remodelling involves a switch in the lung microbiota from a high biodiversity/low pathogen state to a low biodiversity/pathogen-dominated state. Bile acids are particularly associated with the dominance of Proteobacterial pathogens. The ability of bile acids to impact directly on both the lung microbiota and the host response offers a unifying principle underpinning the pathogenesis of CF. The modulating role of bile acids in lung microbiota dysbiosis and inflammation could offer new potential targets for designing innovative therapeutic approaches for respiratory disease.
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Urso A, Leiva-Juárez MM, Briganti DF, Aramini B, Benvenuto L, Costa J, Nandakumar R, Gomez EA, Robbins HY, Shah L, Aversa M, Sonnet JR, Arcasoy S, Cremers S, D'Ovidio F. Aspiration of conjugated bile acids predicts adverse lung transplant outcomes and correlates with airway lipid and cytokine dysregulation. J Heart Lung Transplant 2021; 40:998-1008. [PMID: 34183226 DOI: 10.1016/j.healun.2021.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/08/2021] [Accepted: 05/20/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Duodeno-gastroesophageal reflux aspiration is associated with chronic lung allograft dysfunction (CLAD). Reflux aspirate can contain bile acids (BA), functional molecules in the gastro-intestinal tract with emulsifying properties. We sought to determine and quantify the various BA species in airways of the lung transplant recipients to better understand the various effects of aspirated BA that contribute to post-transplantation outcomes. METHODS Bronchial washings (BW) were prospectively collected from lung transplant recipients and subsequently assayed by liquid chromatography-mass spectrometry for 13 BA and 25 lipid families. Patients were monitored for CLAD, rejection, inflammation and airway infections. RESULTS Detectable BA were present in 45/50 patients (90%) at 3 months after transplant. Elevated BA and predominance of conjugated species were independent predictors of CLAD (hazard ratio 7.9; 95% confidence interval 2.7-23.6; p < 0.001 and 7.3; 2.4-22; p < 0.001, respectively) and mortality (hazard ratio 4.4; 1.5-12.7; p = 0.007 and 4.8; 1.4-15.8; p = 0.01, respectively). High BA associated with increased positive bacterial cultures (60% vs 25%, p = 0.02). Primary conjugated species independently correlated with the rate of bacterial cultures during the first-year post-transplant (Beta coefficient: 0.77; 0.28-1.26; p = 0.003) and changes in airway lipidome and cytokines. CONCLUSIONS Higher BA levels and predominance of conjugated BA are independent predictors of chronic lung allograft dysfunction, mortality and bacterial infections. Primary conjugated BA are related to distinct changes in airway lipidome and inflammatory cytokines. This elucidates novel evidence into the mechanism following BA aspiration and proposes novel markers for prediction of adverse post-transplant outcomes.
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Affiliation(s)
- Andreacarola Urso
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Miguel M Leiva-Juárez
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Domenica F Briganti
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Beatrice Aramini
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Luke Benvenuto
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Joseph Costa
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Renu Nandakumar
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Estela Area Gomez
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Hilary Y Robbins
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Lori Shah
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Meghan Aversa
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Joshua R Sonnet
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY
| | - Selim Arcasoy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY
| | - Serge Cremers
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Frank D'Ovidio
- Department of Surgery, Division of Cardiac ,Thoracic, & Vascular Surgery, Columbia University Irving Medical Center, New York, NY.
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Esophageal Motility Disorders Associated With Death or Allograft Dysfunction After Lung Transplantation? Results of a Retrospective Monocentric Study. Clin Transl Gastroenterol 2021; 11:e00137. [PMID: 32352712 PMCID: PMC7145052 DOI: 10.14309/ctg.0000000000000137] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Pathological gastroesophageal reflux (GER) is a known risk factor for bronchiolitis obliterans syndrome (BOS) after lung transplantation. This study aimed at determining whether functional esophageal evaluation might predict BOS occurrence and survival in this setting. METHODS Ninety-three patients who underwent esophageal high-resolution manometry and 24-hour pH-impedance monitoring within the first year after lung transplantation were retrospectively included. A univariable analysis was performed to evaluate the parameters associated with GER disease and BOS occurrence. The Cox regression model was used to identify the prognostic factors of death or retransplantation. RESULTS Thirteen percent of patients exhibited major esophageal motility disorders and 20% pathological GER. GER occurrence was associated with younger age, cystic fibrosis, and hypotensive esophagogastric junction. Within a median follow-up of 62 months, 10 patients (11%) developed BOS, and no predictive factors were identified. At the end of the follow-up, 10 patients died and 1 underwent retransplantation. The 5-year cumulative survival rate without retransplantation was lower in patients with major esophageal motility disorders compared with that in those without (75% vs 90%, P = 0.01) and in patients who developed BOS compared with that in those without (66% vs 91%; P = 0.005). However, in multivariable analysis, major esophageal motility disorders and BOS were no longer significant predictors of survival without retransplantation. DISCUSSION Major esophageal motility disorders and BOS were associated with allograft survival in lung transplantation in the univariable analysis. Although the causes of this association remain to be determined, this observation confirms that esophageal motor dysfunction should be evaluated in the context of lung transplantation.
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Gastroesophageal Reflux and Esophageal Motility Disorder After Lung Transplant: Influence on the Transplanted Graft. Transplant Proc 2021; 53:1989-1997. [PMID: 33994181 DOI: 10.1016/j.transproceed.2021.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/10/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Esophageal pathology has been identified as a bad prognostic factor in lung transplantation (LTx). This study aims to assess the esophageal disorders present post-LTx, under treatment with proton pump inhibitors, and their putative impact on the graft. METHODS Prospective, observational study of LTx patients. Digestive factors were assessed by manometry and pH-metry at 6 months post-LTx and under proton pump inhibitor treatment. We assessed the association between esophageal disorders and graft function and acute rejection (AR) and chronic lung allograft dysfunction (CLAD). RESULTS Out of 76 post-LTx patients, 27% showed gastroesophageal reflux disease (GERD), 55% showed inadequate gastric inhibition, and 59% showed esophageal motility disorders (EMDs). We observed a greater incidence of AR from 3 months post-LTx in the presence of EMD (P ≤ .05). No significant differences were observed in GERD or EMD prevalence or in survival between patients with or without CLAD. The maximum forced expiratory volume in 1 second (FEV1) achieved after bilateral LTx was significantly (P = .022) lower in patients with EMD vs without EMD. CONCLUSION At 6 months post-LTx, there is a high percentage of esophageal disorders (GERD and EMDs). No esophageal disorder is associated with CLAD or with survival, although EMDs are associated with a greater incidence of AR and lower graft function.
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Kolbeinsson HM, Lawson C, Banks-Venegoni A, Girgis R, Scheeres DE. Treatment of Gastroesophageal Reflux Disease After Lung Transplant Using Radiofrequency Ablation to the Lower Esophageal Sphincter (Stretta Procedure). Am Surg 2021; 88:1663-1668. [PMID: 33719597 DOI: 10.1177/0003134821998678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is associated with chronic lung allograft dysfunction after lung transplant. Treating GERD after lung transplant has been shown to improve lung allograft function. This case series describes the efficacy of the Stretta procedure to control GERD after lung transplant at our institution. METHODS Eleven patients underwent the Stretta procedure at our institution for GERD after lung transplant during the years 2016-2017. Pre- and post-Stretta reflux parameters were gathered. Pulmonary function was followed up until subsequent fundoplication surgery, death, or end of study observation. RESULTS Reflux on esophagram was noted in 9 patients before Stretta and 8 patients after Stretta. The median number of acid reflux events was 31.5 vs. 26 after Stretta (P = .95), and median percent time in reflux was 17.7% before vs. 14.5% after Stretta (P = .76). Median DeMeester score before Stretta was 65.5 (range: 33.2-169.8) vs. 42.5 (range: 19.2-109.8) after the procedure (P = .14). Median lower esophageal resting pressure was 20.7 mm Hg (n = 7) compared to 25.9 mm Hg (n = 9) on post-Stretta follow-up (P = .99). Median FEV1% predicted was 84% (41-97%) before compared to 71% (23-108%) at 1 year after the procedure (P = .14). Seven patients required fundoplication surgery for continued reflux. All patients were on triple immunosuppression, most commonly prednisone, tacrolimus, and mycophenolate (n = 9). DISCUSSION The Stretta procedure did not provide expected results at our institution after lung transplant surgery. Based on our limited series, we do not recommend routine use of the Stretta procedure for management of GERD in lung transplant patients.
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Affiliation(s)
- Hordur M Kolbeinsson
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA.,Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Cameron Lawson
- Spectrum Health Lung Transplantation Program, Grand Rapids, MI, USA
| | - Amy Banks-Venegoni
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA.,Michigan State College of Human Medicine, Grand Rapids, MI, USA.,Division of General Surgery, 3591Spectrum Health Medical Group, Grand Rapids, MI, USA
| | - Reda Girgis
- Michigan State College of Human Medicine, Grand Rapids, MI, USA.,Spectrum Health Lung Transplantation Program, Grand Rapids, MI, USA
| | - David E Scheeres
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA.,Michigan State College of Human Medicine, Grand Rapids, MI, USA.,Division of General Surgery, 3591Spectrum Health Medical Group, Grand Rapids, MI, USA
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Johnson DY, Gallo CJR, Agassi AM, Sag AA, Martin JG, Pabon-Ramos W, Ronald J, Suhocki PV, Smith TP, Kim CY. Percutaneous gastrojejunostomy tubes: Identification of predictors of retrograde jejunal limb migration into the stomach. Clin Imaging 2020; 70:93-96. [PMID: 33137642 DOI: 10.1016/j.clinimag.2020.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/30/2020] [Accepted: 10/17/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach. MATERIALS AND METHODS Retrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis. RESULTS A total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13-0.56, p < 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16-0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure. CONCLUSION To minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.
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Affiliation(s)
- David Y Johnson
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America.
| | - Christopher J R Gallo
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Andre M Agassi
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Alan A Sag
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Jonathan G Martin
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Waleska Pabon-Ramos
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - James Ronald
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Paul V Suhocki
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Tony P Smith
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Charles Y Kim
- Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America
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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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Davidson JR, Franklin D, Kumar S, Mohammadi B, Dawas K, Eaton S, Curry J, De Coppi P, Abbassi-Ghadi N. Fundoplication to preserve allograft function after lung transplant: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:858-866. [DOI: 10.1016/j.jtcvs.2019.10.185] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/08/2019] [Accepted: 10/25/2019] [Indexed: 12/29/2022]
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Hogea SP, Tudorache E, Pescaru C, Marc M, Oancea C. Bronchoalveolar lavage: role in the evaluation of pulmonary interstitial disease. Expert Rev Respir Med 2020; 14:1117-1130. [PMID: 32847429 DOI: 10.1080/17476348.2020.1806063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL), a noninvasive, well-tolerated procedure is an important diagnostic tool that can facilitate the diagnosis of various lung diseases. This procedure allows the assessment of large alveolar compartments, by providing cells as well as non-cellular constituents from the lower respiratory tract. Alterations in BAL fluid and cells ratio reflects pathological changes in the lung parenchyma. In some cases, clinicians use BAL as a differential diagnosis guide for interstitial lung disease. AREAS COVERED In this review, we summarized the diagnostic criteria for BAL in interstitial lung diseases, pulmonary infections, lung cancer and other pathologies such as fat embolism, gastroesophageal reflux and collagen vascular disease. For this review, we have selected scientific papers published in the PubMed database in our area of interest. We aimed to highlight the usefulness of BAL in respiratory pathology. EXPERT OPINION Although BAL fluid analyzes has an essential role in the diagnostic work-up of many lung pathologies, it should be performed in selected patients. For accurate results, the BAL technique is very important to be standardized.
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Affiliation(s)
- Stanca-Patricia Hogea
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Emanuela Tudorache
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Camelia Pescaru
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Monica Marc
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Cristian Oancea
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
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Chan WW, Ahuja N, Fisichella PM, Gavini S, Rangan V, Vela MF. Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome. Ann N Y Acad Sci 2020; 1482:95-105. [PMID: 32808313 DOI: 10.1111/nyas.14460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/05/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is prevalent and may be associated with both esophageal and extraesophageal syndromes, which include various pulmonary conditions. GERD may lead to pulmonary complications through the "reflux" (aspiration) or "reflex" (refluxate-triggered, vagally mediated airway spasm) mechanisms. While GERD may cause or worsen pulmonary disorders, changes in respiratory mechanics due to lung disease may also increase reflux. Typical esophageal symptoms are frequently absent and objective assessment with reflux monitoring is often needed for diagnosis. Impedance monitoring should be considered in addition to traditional pH study due to the involvement of both acidic and weakly acidic/nonacidic reflux. Antireflux therapy may improve outcomes of some pulmonary complications of GERD, although careful selection of a candidate is paramount to successful outcomes. Further research is needed to identify the optimal testing strategy and patient phenotypes that would benefit from antireflux therapy to improve pulmonary outcomes.
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Affiliation(s)
- Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nitin Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P Marco Fisichella
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vikram Rangan
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
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Prolonged Wireless pH Monitoring or 24-Hour Catheter-Based pH Impedance Monitoring: Who, When, and Why? Am J Gastroenterol 2020; 115:1150-1152. [PMID: 32483007 DOI: 10.14309/ajg.0000000000000648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Increased Acid Exposure on Pretransplant Impedance-pH Testing Is Associated With Chronic Rejection After Lung Transplantation. J Clin Gastroenterol 2020; 54:517-521. [PMID: 32091450 DOI: 10.1097/mcg.0000000000001331] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL The goal of this study was to assess the relationship between pretransplant measures of reflux and longer-term outcomes of chronic allograft rejection in lung transplant recipients. BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a primary measure of morbidity and mortality following lung transplantation, and a manifestation of chronic lung allograft dysfunction (CLAD). Acid reflux has been associated with early allograft injury through a proposed mechanism of aspiration and activation of the inflammatory cascade, but its association with chronic rejection is unclear. STUDY This was a retrospective cohort study of lung transplant recipients undergoing impedance-pH testing off proton pump inhibitor from 2007 to 2016. Patients with pretransplant antireflux surgery were excluded. Time-to-event analysis using the Cox proportional hazards model was applied to assess the relationship between pretransplant reflux measures and the development of BOS, defined histologically and clinically. A secondary analysis was completed using CLAD as the outcome variable. RESULTS Fifty-one subjects (59% men, mean age: 56, mean follow-up: 2.2 y) met inclusion criteria for the study. The BOS endpoint was reached in 13 subjects (28%). In time-to-event analyses, BOS was associated with increased acid exposure, defined as >4.2% of time with pH<4 [hazard ratio (HR): 4.18; 95% confidence interval (CI): 1.31-13.4; P=0.01], and elevated DeMeester score >14.7 (HR: 3.08; 95% CI: 1.02-9.26; P=0.04), with confirmation from Kaplan-Meier analyses. The secondary analysis demonstrated a similar association between increased acid exposure and CLAD (HR: 3.28; 95% CI: 1.09-9.88; P=0.03), which persisted on multivariate models. CONCLUSION Increased acid exposure on pretransplant reflux testing was associated with the development of BOS and CLAD, both measures of chronic allograft rejection, after lung transplantation, and may provide clinically relevant information to improve lung allograft survival through aggressive reflux management.
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Yoshiyasu N, Sato M. Chronic lung allograft dysfunction post-lung transplantation: The era of bronchiolitis obliterans syndrome and restrictive allograft syndrome. World J Transplant 2020; 10:104-116. [PMID: 32864356 PMCID: PMC7428788 DOI: 10.5500/wjt.v10.i5.104] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic lung allograft dysfunction (CLAD) following lung transplantation limits long-term survival considerably. The main reason for this is a lack of knowledge regarding the pathological condition and the establishment of treatment. The consensus statement from the International Society for Heart and Lung Transplantation on CLAD in 2019 classified CLAD into two main phenotypes: Bronchiolitis obliterans syndrome and restrictive allograft syndrome. Along with this clear classification, further exploration of the mechanisms and the development of appropriate prevention and treatment strategies for each phenotype are desired. In this review, we summarize the new definition of CLAD and update and summarize the existing knowledge on the underlying mechanisms of bronchiolitis obliterans syndrome and restrictive allograft syndrome, which have been elucidated from clinicopathological observations and animal experiments worldwide.
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Affiliation(s)
- Nobuyuki Yoshiyasu
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
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Zhang CYK, Ahmed M, Huszti E, Levy L, Hunter SE, Boonstra KM, Moshkelgosha S, Sage AT, Azad S, Zamel R, Ghany R, Yeung JC, Crespin OM, Frankel C, Budev M, Shah P, Reynolds JM, Snyder LD, Belperio JA, Singer LG, Weigt SS, Todd JL, Palmer SM, Keshavjee S, Martinu T. Bronchoalveolar bile acid and inflammatory markers to identify high-risk lung transplant recipients with reflux and microaspiration. J Heart Lung Transplant 2020; 39:934-944. [PMID: 32487471 DOI: 10.1016/j.healun.2020.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a risk factor for chronic lung allograft dysfunction. Bile acids-putative markers of gastric microaspiration-and inflammatory proteins in the bronchoalveolar lavage (BAL) have been associated with chronic lung allograft dysfunction, but their relationship with GERD remains unclear. Although GERD is thought to drive chronic microaspiration, the selection of patients for anti-reflux surgery lacks precision. This multicenter study aimed to test the association of BAL bile acids with GERD, lung inflammation, allograft function, and anti-reflux surgery. METHODS We analyzed BAL obtained during the first post-transplant year from a retrospective cohort of patients with and without GERD, as well as BAL obtained before and after Nissen fundoplication anti-reflux surgery from a separate cohort. Levels of taurocholic acid (TCA), glycocholic acid, and cholic acid were measured using mass spectrometry. Protein markers of inflammation and injury were measured using multiplex assay and enzyme-linked immunosorbent assay. RESULTS At 3 months after transplantation, TCA, IL-1β, IL-12p70, and CCL5 were higher in the BAL of patients with GERD than in that of no-GERD controls. Elevated TCA and glycocholic acid were associated with concurrent acute lung allograft dysfunction and inflammatory proteins. The BAL obtained after anti-reflux surgery contained reduced TCA and inflammatory proteins compared with that obtained before anti-reflux surgery. CONCLUSIONS Targeted monitoring of TCA and selected inflammatory proteins may be useful in lung transplant recipients with suspected reflux and microaspiration to support diagnosis and guide therapy. Patients with elevated biomarker levels may benefit most from anti-reflux surgery to reduce microaspiration and allograft inflammation.
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Affiliation(s)
- Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sarah E Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kristen M Boonstra
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sassan Azad
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ricardo Zamel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Oscar M Crespin
- Division of General Surgery, University Health Network, University of Toronto, Toronto, Canada
| | | | | | - Pali Shah
- Johns Hopkins University Hospital, Baltimore, Maryland
| | | | | | | | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Jamie L Todd
- Duke University Medical Center, Durham, North Carolina
| | | | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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Abstract
GOALS We sought to determine the incidence of jackhammer esophagus (JE) after lung transplantation (LT) and identify potential risk factors for the development of JE after LT. BACKGROUND JE is a rare esophageal motility disorder, and its pathophysiology remains unclear. Lung transplantation has been implicated as a potential risk factor for JE, but the incidence of JE after LT is unknown. STUDY A retrospective cohort of adult patients who underwent LT at 2 tertiary care centers over 7.5 years was reviewed. Analysis was performed on patients who underwent a high-resolution esophageal manometry (EM) study before and after LT. JE was defined according to the latest Chicago classification, version 3.0. RESULTS A total of 57 patients without JE identified on pre-LT EM also underwent an EM study after LT. Fifteen (25.4%) were found to have new JE after LT. Patients with newly diagnosed JE after LT were older (61.3±5.3 y vs. 51.6±15.6 y; P=0.02) and more often had chronic obstructive pulmonary disease (COPD; 47.6% vs. 16.6%; P=0.03) compared with those without COPD. There was a trend toward increased risk for JE among female individuals (60% vs. 33.3%; P=0.07) and those with shorter surgical anastomosis times (75.8±12.2 min vs. 84.4±14.3; P=0.06). There was no significant difference between body mass index, opioid use, pretransplant EM findings, surgical ischemic time, occurrence of gastroparesis, or measured post-LT outcomes between the 2 groups. CONCLUSIONS JE occurs not uncommonly in patients after LT. Older age and COPD pre-LT may be significant risk factors.
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Gualdoni J, Ritzenthaler J, Burlen J, Stocker A, Abell T, Roman J, Nunley DR. Gastroesophageal Reflux and Microaspiration in Lung Transplant Recipients: The Utility of a Single Esophageal Manometry and pH Probe Monitoring Study. Transplant Proc 2020; 52:977-981. [PMID: 32151388 DOI: 10.1016/j.transproceed.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear. METHODS Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX. RESULTS Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively. CONCLUSION Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.
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Affiliation(s)
- J Gualdoni
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States.
| | - J Ritzenthaler
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Burlen
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - A Stocker
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - T Abell
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Roman
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States; Robley Rex VA Medical Center, Louisville, Kentucky, United States
| | - D R Nunley
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
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Kawashima M, Juvet SC. The role of innate immunity in the long-term outcome of lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:412. [PMID: 32355856 PMCID: PMC7186608 DOI: 10.21037/atm.2020.03.20] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Long-term survival after lung transplantation remains suboptimal due to chronic lung allograft dysfunction (CLAD), a progressive scarring process affecting the graft. Although anti-donor alloimmunity is central to the pathogenesis of CLAD, its underlying mechanisms are not fully elucidated and it is neither preventable nor treatable using currently available immunosuppression. Recent evidence has shown that innate immune stimuli are fundamental to the development of CLAD. Here, we examine long-standing assumptions and new concepts linking innate immune activation to late lung allograft fibrosis.
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Affiliation(s)
- Mitsuaki Kawashima
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C Juvet
- Latner Thoracic Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Gastrointestinal Complications. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Posner S, Finn RT, Shimpi RA, Wood RK, Fisher D, Hartwig MG, Klapper J, Reynolds J, Niedzwiecki D, Parish A, Leiman DA. Esophageal contractility increases and gastroesophageal reflux does not worsen after lung transplantation. Dis Esophagus 2019; 32:1-8. [PMID: 31076744 DOI: 10.1093/dote/doz039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 02/28/2019] [Accepted: 04/02/2019] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux and esophageal dysmotility are common in patients with advanced lung disease and are associated with allograft dysfunction after lung transplantation. The effect of transplantation on reflux and esophageal motility is unclear. The aim of this study was to describe the changes in esophageal function occurring after lung transplantation. A retrospective cohort study was performed on lung transplant candidates evaluated at a tertiary care center between 2015 and 2016. A total of 76 patients who underwent lung transplantation had high-resolution manometry and ambulatory pH-metry before and after transplant. Demographic data, esophageal function testing results, and clinical outcomes such as pulmonary function testing were collected and analyzed using appropriate statistical tests and multivariable regression. Of the 76 patients, 59 (78%) received a bilateral transplant. There was a significant increase in esophageal contractility posttransplant, with an increase in median distal contractile integral from 1470 to 2549 mmHg cm s (P < 0.01). There were 19 patients with Jackhammer esophagus posttransplant, including 15 patients with normal motility pretransplant. Nine patients with ineffective or fragmented peristalsis pretransplant had normal manometry posttransplant. Abnormal pH-metry was observed in 35 (46%) patients pretransplant and 29 (38%) patients posttransplant (P = 0.33). Patients with gastroesophageal reflux disease posttransplant had less improvement in pulmonary function at one year, as measured by forced expiratory volume (P = 0.04). These results demonstrate that esophageal contractility increases significantly after lung transplantation, with an associated change in motility classification. In comparison, gastroesophageal reflux does not worsen, but is associated with worse pulmonary function, posttransplant.
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Affiliation(s)
| | | | | | | | - Deborah Fisher
- Division of Gastroenterology.,Duke Clinical Research Institute
| | | | | | - John Reynolds
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology.,Duke Clinical Research Institute
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