Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States.
Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States.
World J Gastroenterol. 2023 Jun 7;29(21):3292-3301. doi: 10.3748/wjg.v29.i21.3292.
Gastroesophageal reflux is associated with poorer outcomes after lung transplant, likely through recurrent aspiration and allograft injury. Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes, the role of esophageal manometry in the assessment of lung transplant patients remains debated, and the impact of esophageal dysmotility on transplant outcomes is unclear. Of particular interest is ineffective esophageal motility (IEM) and its associated impact on esophageal clearance.
To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.
This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018. Patients with pre-transplant anti-reflux surgery were excluded. Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing. Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection, defined histologically per International Society of Heart and Lung Transplantation guidelines. Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery, last clinic visit, or death. Fisher's exact test for binary variables and student's -test for continuous variables were performed to assess for differences between groups.
Of 184 subjects (54% men, mean age: 58, follow-up: 443 person-years) met criteria for inclusion. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis (41%). During the follow-up period, 60 subjects (33.5%) developed acute rejection. The all-cause mortality was 16.3%. Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection [hazard ratio (HR): 1.984, 95%CI: 1.03-3.30, = 0.04], confirmed on Kaplan-Meier curve. On multivariable analysis, IEM remained independently associated with acute rejection, even after controlling for potential confounders such as the presence of acid and nonacid reflux (HR: 2.20, 95%CI: 1.18-4.11, = 0.01). Nonacid reflux was also independently associated with acute rejection on both univariate (HR: 2.16, 95%CI: 1.26-3.72, = 0.005) and multivariable analyses (HR: 2.10, 95%CI: 1.21-3.64, = 0.009), adjusting for the presence of IEM.
Pre-transplant IEM was associated with acute rejection after transplantation, even after controlling for acid and nonacid reflux. Esophageal motility testing may be considered in lung transplant to predict outcomes.
胃食管反流与肺移植后较差的结果相关，可能通过反复吸入和移植物损伤。尽管先前的研究已经证明了阻抗-pH 结果与移植结果之间的关系，但食管测压在评估肺移植患者中的作用仍存在争议，食管动力障碍对移植结果的影响尚不清楚。特别有趣的是无效食管动力（IEM）及其对食管清除的相关影响。
评估肺移植前 IEM 诊断与肺移植后急性排斥反应之间的关系。
这是一项对 2007 年至 2018 年在三级护理中心进行的肺移植受者的回顾性队列研究。排除了肺移植前抗反流手术的患者。从肺移植前的食管功能测试中记录测压和反流诊断。应用 Cox 比例风险模型进行时间事件分析，以评估根据国际心肺移植协会指南定义的首次急性细胞排斥反应的结局。未达到该终点的受试者在移植后抗反流手术、最近的临床就诊或死亡时被删失。采用 Fisher 确切概率检验和学生 t 检验评估组间差异。
184 例患者（54%为男性，平均年龄 58 岁，随访 443 人年）符合纳入标准。间质性肺纤维化是主要的肺部诊断（41%）。在随访期间，60 例患者（33.5%）发生急性排斥反应。全因死亡率为 16.3%。单变量时间事件分析表明，IEM 与急性排斥反应显著相关[风险比（HR）：1.984，95%CI：1.03-3.30， = 0.04]，Kaplan-Meier 曲线也证实了这一点。多变量分析表明，即使在控制了酸和非酸反流等潜在混杂因素后，IEM 仍与急性排斥反应独立相关（HR：2.20，95%CI：1.18-4.11， = 0.01）。非酸性反流在单变量（HR：2.16，95%CI：1.26-3.72， = 0.005）和多变量分析（HR：2.10，95%CI：1.21-3.64， = 0.009）中也与急性排斥反应独立相关，同时调整了 IEM 的存在。
肺移植前 IEM 与移植后急性排斥反应相关，即使在控制酸和非酸反流后也是如此。食管动力检查可考虑用于肺移植以预测结果。
