SAN FRANCISCO — The number of lung retransplantations is surging, and the wait times for retransplantation is evaporating since adoption of the current lung allocation system in 2005, Dr. Steven M. Kawut said.
A retrospective study also found that survival after lung retransplantation has improved in the modern era but still is not as good as after a first lung transplant. Patients undergoing lung retransplantation within 30 days of the initial transplant are three times more likely to die than patients undergoing retransplantation more than 30 days after the first lung transplant, he and his associates reported at the annual meeting of the International Society for Heart and Lung Transplantation.
“Early retransplantation really should be avoided,” said Dr. Kawut of Columbia University, New York.
In general, only 15% of patients who undergo lung transplant survive to 5 years. Repeating lung transplantation can keep some patients alive but the procedure is more challenging, the patients more vulnerable, and the ethical issues more complex, according to Dr. Kawut.
The investigators compared transplantation registry data on 205 patients who underwent lung retransplantation from 2001 through May of 2006 (the modern-era group) with data on a historical cohort that underwent lung retransplantation from 1990 to 2000, and a third group of patients who underwent primary lung transplantation in the modern era.
The number of lung retransplantations ranged from 25 to 33 per year in 2001–2004 and leaped dramatically to 71 in 2005, when the Organ Procurement and Transplantation Network adopted the new Lung Allocation Score (LAS). The study includes 13 of the 56 retransplantations performed in 2006. The median wait for a lung retransplantation in the modern era was 6 months before introduction of the LAS and 1 month since then.
Pre-LAS, 75% of recipients got lung retransplants within 19 months and the rest waited more than 19 months. Under the LAS system, 25% of recipients underwent lung retransplantation within 3 days of being wait-listed—“unbelievable!” Dr. Kawut remarked. Half of lung retransplantations occurred within 1 month, and 75% of retransplantations were performed within 2 months.
At 1 year after retransplantation, 62% of patients were alive. At 5 years, 45% were alive. Compared with retransplantations done before 2001, patients in the modern era were 40% more likely to survive. Compared with patients undergoing a first lung transplant in the modern era, those getting retransplanted in the same time period were 40% more likely to die after controlling for the potentially confounding effects of age, sex, race, the initial diagnosis, the type of transplant procedure, and the use of mechanical ventilation.
A statistically significant increase in risk for death if the retransplanted lungs came from a male donor should be considered with some skepticism because other studies have not shown this, Dr. Kawut said.
To help physicians advise patients considering lung retransplantation, the investigators analyzed data on a subset of 110 patients who survived at least 1 year after the procedure. They found an “absolutely dismal” survival rate of 14% for those who underwent retransplantation within 30 days of the primary transplant and 1-year survival in 58% who underwent retransplantation more than 30 days after the initial surgery—“still not perfect, but much better than 14%,” he said. “Numbers like these may be more useful for the patient in your office.”
The most difficult part of lung retransplantation is the ethical issues involved in giving one patient two opportunities for transplant when that probably denies other patients of even one transplant, because of donor organ shortages. Attention to this ethical issue “trails far behind our ability to do the procedure,” he said.