Chest
Volume 124, Issue 5, November 2003, Pages 1689-1693
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Clinical Investigations
TRANSPLANTS
Lung Transplantation Exacerbates Gastroesophageal Reflux Disease*

https://doi.org/10.1378/chest.124.5.1689Get rights and content

Introduction

A high prevalence of gastroesophageal reflux (GER) has been reported in lung transplant recipients and is possibly linked to the development of bronchiolitis obliterans syndrome. The etiology of posttransplant GER remains unknown but may occur due to the transplant operation or posttransplant medications, or represent preexisting GER disease. We evaluated these possibilities by studying the nature and severity of GER in a cohort of patients before and after lung transplantation.

Methods

Total, upright, and supine acid contact times were recorded in lung transplant recipients who underwent 24-h pH studies before and after transplantation. Patients also underwent esophageal manometry and gastric-emptying studies. Medications for acid suppression and gastric motility were discontinued before testing. Paired comparison between pretransplant and posttransplant results was performed using a paired t test.

Results

Twenty-three patients were included in the analysis. The mean age was 51.5 years, and native diseases included emphysema (n = 11), cystic fibrosis (n = 4), pulmonary fibrosis (n = 3), and others (n = 5). Posttransplant studies occurred a median of 100 days after transplantation. After lung transplantation, the total acid contact time increased a mean of 3.7% (p = 0.03) and the supine acid contact time increased a mean of 6.4% (p = 0.019). Thirty-five percent (8 of 23 patients) had abnormal acid contact times before transplant, and 65% (15 of 23 patients) had abnormal acid contact after transplant. Changes in acid contact times were not explained by changes in esophageal or gastric motility. Only 20% (3 of 15 patients) with abnormal posttransplant pH studies were symptomatic.

Conclusions

There is a significant increase in GER after lung transplantation, as measured objectively by 24-h pH studies, despite a lack of symptoms in most patients. Further research is needed to determine the physiologic mechanisms of posttransplant GER and its impact on long-term allograft function.

Section snippets

Materials and Methods

The transplant population included all patients undergoing lung transplantation at Duke University Medical Center. From 1992 to January 2001, there were 320 lung transplant operations performed. Standardized surgical techniques were used for the operations, and these are described elsewhere.12 Patients generally received postoperative immunosuppression with cyclosporine A (5 to 10 mg/kg/d), azathioprine (1 to 2 mg/kg/d), and corticosteroids (methylprednisolone, 125 mg q12h for the first 48 h,

Results

A total of 23 of 137 patients (16.8%) underwent both pretransplant and posttransplant reflux studies at the time of this analysis. The demographic characteristics of the patient population are displayed in Table 1. The mean patient age was 51.5 years, and a majority of the patients were female and underwent bilateral lung transplantation. Pretransplant studies were performed a median of 66 days prior to transplant (range, 1 to 443 days), and posttransplant studies occurred a median of 100 days

Discussion

Lung transplantation has become an accepted treatment modality for end-stage lung disease, but long-term outcomes remain limited, with 5-year survival at approximately 50%.17 The entity of chronic rejection, which is very common, has been difficult to define, but histologic obliterative bronchiolitis (OB) is considered indicative of chronic allograft rejection.18 The pathogenesis of OB remains poorly understood, though many mechanisms including immunologic, infectious, and perioperative factors

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Supported in part by a clinical research grant from the CF Foundation.

Performed at Duke University Medical Center.

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