Differential outcomes with early and late repeat transplantation in the era of the lung allocation score

Abstract

Background: Rates of repeat lung transplantation have increased since implementation of the lung allocation score (LAS). The purpose of this study is to compare survival between repeat (ReTx) and primary (LTx) lung transplant recipients in the LAS era.

Methods: We extracted data from 9,270 LTx and 456 ReTx recipients since LAS implementation, from the United Network for Organ Sharing registry. Propensity scoring was used to match ReTx and LTx recipients. Kaplan-Meier analysis compared survival between LTx and ReTx groups, with and without stratification based on time between first and second transplant. Multivariable Cox models estimated predictors of survival in lung recipients.

Results: Comparing all ReTx to LTx demonstrates a survival advantage for LTx that is diminished with propensity score matching (p = 0.174). Considering LTx against ReTx greater than 90 days after the initial procedure, there are similar survival results (p < 0.067). In contrast, ReTx within 90 days was associated with a survival disadvantage that persisted despite matching (p = 0.011). In ReTx populations, factors conferring worse outcomes include intensive care unit admission, unilateral transplantation, poor functional status, and primary graft dysfunction as the indication for retransplantation (p < 0.05).

Conclusions: Late lung retransplantation appears to be as beneficial as primary transplantation in propensity-matched patients. However, survival is severely diminished in those retransplanted less than 90 days after primary transplantation. The utility of early retransplantation needs to be carefully weighed in light of risks.

Fig 1. Number and proportion of lung retransplantation performed in the United States by year (LAS = lung allocation score)

Fig 2. Kaplan-Meier survival curves comparing (A) unmatched and (B) matched groups of primary and repeat lung recipients

Fig 3. Kaplan-Meier survival curves comparing survival in (A) Early (< 90 days) and (B) late (≥ 90 days) retransplantation with survival in unmatched and matched groups of primary lung recipients

Fig 4. Survival by time between initial and repeat transplantation

Fig 5. Comparative survival of lung retransplantation before and after the implementation of the lung allocation score (LAS)