PURPOSE: Gastric-to-pulmonary aspiration has been implicated as a mechanism for acute allograft rejection following lung transplantation (LT). Whether the presence of a hiatal hernia (HH) contributes to an aspiration risk and subsequent rejection is unclear. We aimed to determine the prevalence of HH following LT and whether it associates with acute rejection and small-airways inflammation.
METHODS: In this retrospective study, 196 consecutive patients who underwent LT at a tertiary medical center between 2001 and 2008 were identified, and followed-up for a median of 3.5 years. Thirteen were excluded due to the lack of testing to identify HH, either by esophagram, computed tomography, or endoscopy. The occurrence of acute rejection was determined from bronchoscopic lung biopsies, and graded based on the 1996 International Society for Heart and Lung Transplantation nomenclature. Comparisons were made between those with at least moderate (grade≥A3) versus lower grade acute rejection. For small-airways inflammation (lymphocytic bronchiolitis), we compared those with high (grade≥B3) versus low grade inflammation. Statistical signficance was determined by Fisher’s exact test.
RESULTS: In the 183 patients enrolled, 57% were male and 43% were female and the median age was 59 years (interquartile range:50-65). The majority of transplants were for interstitial lung disease (47%) and chronic obstructive pulmonary disease (33%). HH (post-transplant) was present in 28% of the cohort. Acute rejection occurred in 93% of patients; 11% were at least moderate (≥A3). Of those with a HH, 14% developed at least moderate rejection, compared with 10% without a HH (p=0.44). Small-airways inflammation occurred in 87% of patients, but only 3 had high-grade (≥B3) inflammation, all of whom were in the HH group (p=0.021).
CONCLUSIONS: HH may be seen in over a quarter of patients post-LT. Its presence did not appear to increase the risk of acute rejection, but may be associated with high-grade small-airways inflammation.
CLINICAL IMPLICATIONS: The finding of a HH alone should not increase the concern for acute allograft rejection, however, its potential contribution to small-airways inflammation and the subsequent development of bronchiolitis obliterans requires further investigation.
DISCLOSURE: The following authors have nothing to disclose: Sheena Boodoo, Augustine Lee, Charles Burger, Lesley Houghton, David Erasmus, Francisco Alvarez, Kenneth DeVault, Ceasar Keller
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