Low Center Volume (rel. risk = 2.04)

Preop Ventilator Support (rel. risk = 1.8)

UNOS Status

Total Number of Transplants

Donor Age (rel. risk = 2.2)

Organ Ischemia (rel. risk = 1.7)

dysfunction, intractable airway healing problems, and obliterative bronchiolitis — all conditions necessitating a second transplant. 6 Retransplantation accounts for 5-10% of all pulmonary transplants. Obliterative bronchiolitis, first described in the lung transplant population in 1984, is an inflammatory disorder of the small airways leading to obstruction and destruction of pulmonary bronchioles. It can occur after isolated single- and bilateral-lung transplantation and is found to some degree in up to two-thirds of all lung transplant recipients. The main risk factor for the development of this disease is recurrent, severe, and persistent acute lung rejection. It is not, however, associated with any other known recipient variables (such as, age, sex, or indication for primary transplantation.) The fibrosis resulting from obliterative bronchiolitis is irreversible, and there is no satisfactory treatment for the disease other than retransplantation. (Table E6.1)

The pulmonary retransplant registry was established in 1991 to help assess the outcome and survival after pulmonary transplantation. Analysis of the registry data indicates that a prior lung transplant increases the risk of 1-year mortality by more than three-fold. (Table E6.2) On multivariate analysis, survival was not significantly different according to the age, sex, original diagnosis, or the cytomega-lovirus status of the recipient. Similarly, survival did not depend on the indication for retransplantation. The most significant predictors of survival were the preoperative ambulatory status of the recipient, as well as the preoperative ventilatory status. An ambulatory recipient was defined as a patient who was able to walk at least 50m. with or without assistance, immediately before retransplantation. In addition, there is an association between survival and the total center volume of retransplantation and between survival and the interval length between transplant procedures. There was no significant survival difference according to the type of retransplantation procedure that was performed (single versus bilateral lung transplants). Patients with and without an old retained contralateral graft have similar survival and pulmonary function.

Opportunistic infection is the leading cause of death after pulmonary retransplantation. 7 Recently, retransplant deaths due to infectious causes have declined, but the percentage of deaths caused by recurrent bronchiolitis obliter-ans has increased. The remainder of the deaths are due to acute failure of the second graft early after reoperation and airway complications. Death due to these complications has remained relatively constant. As with cardiac retransplant recipients, pulmonary retransplant recipients maintain good long-term functional status and the majority do not require supplemental oxygenation. Seventy-nine percent of all retransplant recipients are free of bronchiolitis obliterans at 1 year, 64% at 2 years, and 56% at 3 years. The prevalence of severe disease was 12% at 1 year, 15% at 2 years, and 32% at 3 years, comparable to primary lung transplantation data. Indeed, this shows that the pulmonary function of surviving retrans-plant recipients is preserved as well as that in recipients of first-time lung grafts.

This data suggests that lung retransplantation should be limited to ambulatory, non-ventilated patients and perhaps the procedure should only be performed in centers with extensive experience in pulmonary retransplantation. Survival after pulmonary retransplantation can be comparable to that after primary lung trans-

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