Second lung transplant outcomes are detailed in recent analysis

Over half of eligible patients die on waitlist, or have no record of being on one

Lindsey Shapiro, PhD avatar

by Lindsey Shapiro, PhD |

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More than half of the cystic fibrosis (CF) patients who may have been eligible for a second lung transplant died while on a waitlist or had no record of being placed on one, according to a recent analysis in the U.S. and Canada.

Among those who did have a re-transplantation, survival rates after the second procedure were lower than the first surgery, with survival linked to age and genetic status.

The study, “Cystic fibrosis survival outcomes following second lung transplant: The north American experience,” was published in Clinical Transplantation.

For some patients, irreversible lung damage over time will require a lung transplant. These transplants result in significantly better lung function and higher quality of life.

A person’s immune system can recognize the donor lungs as foreign, however, and launch an attack against them, which is known as transplant rejection. This can result in chronic lung allograft dysfunction (CLAD), or recurring end-stage lung disease.

Therapeutic options once CLAD occurs are in short supply and some patients may be considered for a re-transplant. Success rates and clinical predictors of survival after a re-transplant haven’t been well established, leading scientists in North America to examine data from patients who had a second lung transplant in the U.S. or Canada between 2005-2019. Data were obtained from the Canadian CF Registry and the CF Foundation Patient Registry, and linked to the United Network for Organ Sharing.

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Outcomes for those who had a second transplant

The scientists identified 1,226 people who’d undergone a first transplant and may be eligible for a second one based on their clinical presentation. Eligibility was an estimate based on clinical factors, but wasn’t definitively established.

Overall, 818 people were on a waitlist for a second transplant. That number included 254 people (31%) who died waiting, 395 (48%) who had a second transplant, and 169 (21%) who were still alive and on the list. The remaining 408 people died without evidence that they’d been listed for a re-transplant.

Most people (95%) who received a second transplant were adults and had a median age at re-transplant of 30.1. A small number (27) were transplanted within the first year after a first transplant, referred to as early transplant. The rest received a second transplant more than a year after a first one, or late transplant. A total of 218 post-transplant deaths were recorded among the 395 people who were re-transplanted.

Survival rates were 77.4%, 52%, and 39.4% after one, three, and five years, respectively, with a median survival time of 3.3 years. These rates were similar between the early and late transplant groups.

These rates are lower than what has been reported after a first lung transplant. For example, previously published findings indicate the one-, three-, and five- year survival rates after a first transplant were 88.3%, 71.8%, and 60.3%, respectively, in the U.S.. In Canada, the rates were and 90.5%, 79.9%, and 69.7%, respectively.

This worse prognosis after re-transplant is likely because the procedure is more complex and riskier, and is therefore to be expected, the authors said.

Certain clinical factors may also influence prognosis after re-transplantation.

Particularly, patients with disease-causing mutations in the CFTR gene belonging to Class I-III are at a higher risk of death than those with Class IV-V mutations. Survival was also better in older and younger patients over middle-age patients.

Some patients died on waitlist or weren’t recorded

While the analysis focused on outcomes of a second transplant, it didn’t account for those who might have been eligible for re-transplant but didn’t get the opportunity, the researchers said. More than half of patients deemed eligible in the analysis either died on the waiting list or died without record of ever being placed on it.

Because eligibility was just an estimate, it’s possible some patients were simply deemed ineligible for a second transplant by their healthcare team, but this wasn’t evident in the available records.

“Unfortunately, we were unable to tease out whether or not the individuals who died without transplant in our cohort missed the opportunity or whether re-transplant was considered and deemed not to be an acceptable therapeutic option,” the researchers wrote, noting the findings nevertheless highlight a need to understand why eligible patients might not receive a second transplant. “This would be an important area of future study especially since it is anticipated that a significant proportion of CF transplants in the era of highly effective modulators will likely be re-transplants rather than de-novo [first] lung transplants.”