Review
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Apr 24, 2017; 7(2): 103-116
Published online Apr 24, 2017. doi: 10.5500/wjt.v7.i2.103
Role of gastroesophageal reflux disease in lung transplantation
Kelly E Hathorn, Walter W Chan, Wai-Kit Lo
Kelly E Hathorn, Division of Internal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
Walter W Chan, Wai-Kit Lo, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA 02115, United States
Walter W Chan, Wai-Kit Lo, Harvard Medical School, Boston, MA 02115, United States
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest statement: The authors do not report any conflict of interests and have no financial disclosures relevant to the subjects of the manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Walter W Chan, MD, MPH, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, United States. wwchan@partners.org
Telephone: +1-617-7326389 Fax: +1-617-5250338
Received: August 25, 2016
Peer-review started: August 26, 2016
First decision: October 20, 2016
Revised: January 15, 2017
Accepted: February 8, 2017
Article in press: February 13, 2017
Published online: April 24, 2017
Abstract

Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) and lung transplant outcomes, including acute and chronic rejection. The aim of this review is to discuss the pathophysiology, evaluation, and management of GERD in lung transplantation, as informed by the most recent publications in the field. The pathophysiology of reflux-induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury. Modalities of reflux and esophageal assessment, including ambulatory pH testing, impedance, and esophageal manometry, are discussed, as well as timing of these evaluations relative to transplantation. Finally, antireflux treatments are reviewed, including medical acid suppression and surgical fundoplication, as well as the safety, efficacy, and timing of such treatments relative to transplantation. Our review of the data supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes. Further studies are needed to explore additional objective measures of reflux and aspiration, better compare medical and surgical antireflux treatment options, extend follow-up times to capture longer-term clinical outcomes, and investigate newer interventions including minimally invasive surgery and advanced endoscopic techniques.

Keywords: Lung transplant, Reflux, Aspiration, Rejection, Bronchiolitis obliterans syndrome, Fundoplication

Core tip: Gastroesophageal reflux disease (GERD) has been associated with increased morbidity in lung transplant patients through a proposed pathway of reflux, aspiration, immunomodulation, and allograft injury, culminating in functional decline and rejection. This paper reviews the mechanisms of GERD-induced injury, describes outcome measures important in post-transplant assessment, and discusses the timing and modalities of diagnostic evaluation and management, including medical and surgical antireflux treatment, in optimizing post-transplant outcomes. A greater awareness of the harmful effects of GERD in the lung transplant population is important in the early diagnosis and management of such patients to minimize allograft injury and improve outcomes.