A Combination of Delayed Gastric Emptying and Gastroesophageal Reflux Disease is Associated with Worse Outcomes in Lung Transplantation

Purpose Gastroparesis and GERD are very common conditions in patients with end-stage lung disease and can be exacerbated after lung transplantation (LTx). At our center, we routinely test lung transplant recipients (LTRs) for gastric emptying abnormalities and for GERD at 3 months post-transplant. We hypothesized that LTRs with significant gastroparesis and/or GERD are more likely to develop lung injury leading to subsequent CLAD and death. Methods Among 2812 LTRs transplanted at our center between May 1998 and April 2018, we retrospectively analyzed 1071 patients who had a solid gastric emptying study available within seven months post-transplantation. Delayed gastric emptying (DGE) was defined as > 10% gastric retention at four hours and classified based on severity: mild (10-15%), moderate (16 - 35%), and severe (>35%). We obtained routine 24h pH/impedance testing in LTRs from 2004-2015, where GERD was defined as > 48 episodes of acid or non-acid reflux. 295 patients had both gastric emptying and reflux testing available. Cox proportional hazards models were used to determine the association between DGE, GERD, and combined DGE(moderate/severe)+GERD with time to CLAD or death. Results Mild, moderate, and severe DGE was found in 128 (12%), 163 (15.2%), and 302 (28.2%) patients, respectively. DGE alone was not associated with CLAD or death (HR 0.87 [95% CI 0.64-1.19]; HR 1.06 [95% CI 0.81-1.39]; HR 1.07 [95% CI 0.86-1.35]) for mild, moderate, severe, respectively (Figure 1A). Similarly, evidence of GERD alone was not associated with CLAD or death (abstract ISHLT 2017). However, the combination of moderate-severe DGE and GERD was significantly associated with death (HR: 1.81 [95% CI 1.07-3.05]). Conclusion In a single-center lung transplant cohort study, we observed that while DGE or GERD alone are not individually associated with CLAD or death, patients with both moderate-severe DGE and significant GERD had significantly worse survival.