Survival After Lung Retransplantation in the United States in the Current Era (2004 to 2013): Better or Worse?

Background. To understand the current patient survival after lung retransplantation (LRTx) in the United States, which has historically been worse compared with primary lung transplantation (LPTx). Methods. The United Network for Organ Sharing (UNOS) registry was retrospectively analyzed to determine survival after adult LRTx performed in 604 (2.48%) of 14,850 patients from 2004 to 2013. After exclusions, 582 LRTx and 13,673 LPTx recipients were selected for analysis. Cox proportional hazards regression models were used to determine the prognosticators of survival after LRTx. Survival after LRTx and LPTx were compared using Kaplan-Meier analysis. Results. The median survival after LRTx was 2.6 years compared with 5.6 years after LPTx. One-year, 3-year, and 5-year survival rates were, respectively, 71.1%, 46.3%, and 34.5% for LRTx, and 84.3%, 66.5%, and 53.3% for LPTx (p < 0.001). On multivariate analysis, patients who had LRTx after a greater than 1-year interval survived longer (relative risk [RR] 0.53; 95% confidence interval [CI] 0.34% to 0.88%; p = 0.008). Lower survival was associated with single-lung transplantations (RR 1.49; 95% CI, 1.06% to 2.07%; p = 0.021), transplantations done between 2009 and 2013 (RR 1.40; CI, 1.01% to 1.94%; p = 0.041), multiple (>1) retransplantations (RR 2.55; 95% CI, 1.14% to 5.72%; p = 0.023), and recipients requiring pre-transplantation ventilator support. The only significant donor variable for poor survival was death due to cerebrovascular accidents (RR 1.98; 95% CI, 1.23% to 3.18%; p = 0.004). Conclusions. Patient survival after LRTx in the United States has improved compared with historical data but remains lower than LPTx. Careful recipient selection and preoperative optimization based on the factors identified in our study may help utilize resources better and improve survival after LRTx. Bilateral LRTx should be preferentially performed as much as possible. Poor candidates for LRTx include those requiring retransplantations more than once or within 1 year. Prospective multi-institutional studies are necessary to help better understand the actual role of these factors in LRTx.