Esophageal Hypomotility Is Associated with Rejection Post Lung Transplantation

Abstract

Introduction: Gastroesophageal reflux is a known contributor to rejection after lung transplantation; however, the impact of esophageal dysmotility on graft survival is unknown. The aim of our study is to assess the impact of esophageal dysmotility on lung transplant rejection. Methods: 41 Lung transplant recipients who had high-resolution esophageal manometry (HRM) performed at our institution between 6/2013 and 1/2016 were included. HRM data according to the Chicago Classification, available pH and pH-impedance reports, and transplant outcome data were reviewed. Rejection was determined based on documentation of chronic or acute rejection as defined by transbronchial biopsy or poor FEV1 response post-transplant. Rejection was compared in 4 motility subgroups: 1) hypomotility - all HRM studies with 50% or more failed peristalsis, weak peristalsis, or large breaks, 2) other dysmotility -comprised of achalasia, Jackhammer and esophagogastric junction outflow obstruction (EGJOO), 3) all dysmotility, and 4) normal. We compared mean acid exposure time (AET), DeMeester score (DM), bolus exposure time (BET), and total reflux events across rejection outcome and by motility subgroup in the 38 patients that had both HRM and reflux testing. Results: For our rejection analysis, 23 and 22 patients with pre-transplant HRM and reflux data, respectively, were included. Demographics and clinical data are displayed in table 1. Table 2a displays odds ratios for rejection in the different motility subgroups. A significant difference in rejection was found between the hypomotility group vs all others (odds-ratio 9, p=0.02). Table 2b shows reflux parameters in motility subgroups and by rejection outcome. Of the reflux parameters, elevated total reflux events correlated with rejection in off-PPI studies (p=0.03). All reflux measures were worst in the hypomotility group with the exception of AET, which was highest in the normals. Significant differences in all measures were found between hypomotility and other dysmotility groups.Table 2: Motility and Reflux ResultsConclusion: Hypomotility on pre-transplant HRM is associated with rejection after lung transplantation. This effect is independent of AET and DM and correlates closest with BET and total reflux events. EGJOO without weak peristalsis and hypercontraction appear to have a good prognosis after transplant.Table 1: Clinical Data