Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Division of Gastroenterology, Boston VA Healthcare System, Boston, Massachusetts, USA.
Clin Transl Gastroenterol. 2023 Jan 1;14(1):e00538. doi: 10.14309/ctg.0000000000000538.
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.
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.
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.
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.
胃食管反流与肺移植后较差的结果相关，尽管目前尚无评估/管理的标准方法。我们旨在评估根据常规反流测试指导及时进行抗反流治疗对肺移植后排斥反应结果的影响。
这是一项对三级中心肺移植受者进行的回顾性队列研究。所有患者均在移植前进行了门诊 pH 监测。及时的抗反流治疗定义为在移植后 6 个月内开始质子泵抑制剂或抗反流手术。患者分为三组：正常 pH 监测组（-pH）、pH 升高（+pH）伴及时治疗组和 +pH 伴延迟治疗组。排斥反应的结果包括急性排斥反应、闭塞性细支气管炎综合征和慢性肺移植物功能障碍，根据国际心肺移植协会的标准进行评估。使用 Cox 比例风险模型进行时间相关事件分析。未发生结果的患者在死亡或最后一次就诊时进行删失。
共纳入 175 例患者（59%为男性/平均 56.3 岁/随访时间：496 人年）。多变量分析显示，+pH/延迟治疗患者发生急性排斥反应的风险较高（调整后的危险比[aHR]：3.81[95%可信区间[CI]：1.90-7.64]，P = 0.0002）、闭塞性细支气管炎综合征（aHR：2.22[95%CI：1.07-4.58]，P = 0.03）和慢性肺移植物功能障碍（aHR：2.97[95%CI：1.40-6.32]，P = 0.005）的风险高于+pH/及时治疗患者。同样，与-pH 患者相比，+pH/延迟治疗患者的排斥反应风险也增加（均 P < 0.05）。+pH/及时治疗患者与-pH 患者之间的排斥反应风险无显著差异。抗反流治疗的失败/并发症在各组中均较少且相似。
根据移植前反流测试指导的及时抗反流治疗与降低移植物排斥反应风险相关，并表现出与无反流患者相当的非劣效性。标准化围手术期测试和治疗算法可能有助于及时管理反流，以改善肺移植结果。
