RECURRENCE OF OBLITERATIVE BRONCHIOLITIS AND DETERMINANTS OF OUTCOME IN 139 PULMONARY RETRANSPLANT RECIPIENTS

An international series of pulmonary retransplantation was updated to identify the predictors of outcome and the prevalence and recurrence r ate of obliterative bronchiolitis after operation. The study cohort in cluded 139 patients who underwent retransplantation in 34 institutions in North America and Europe between 1985 and 1994. Eighty patients un derwent retransplantation because of obliterative bronchiolitis, 33 be cause of acute graft failure, 13 because of intractable airway complic ations, 8 because of acute rejection, and 4 because of other indicatio ns. Survivors were followed up for a median of 630 days, with 38 patie nts alive at 1 year, 30 at 2 years, and 16 at 3 years after retranspla ntation. Actuarial survival was 65% +/- 4% at 1 month, 54% +/- 4% at 3 months, 45% +/- 4% at 1 year, 38% +/- 5% at 2 gears, and 36% +/- 5% a t 3 years; nonetheless, of 90-day postoperative survivors, 65% +/- 6% were alive 3 years after retransplantation. Life-table and univariate Cox analysis revealed that more recent year of retransplantation (p = 0.009), identical match of ABO blood group (p = 0.01), absence of a do nor-recipient cytomegalovirus mismatch (p = 0.03), and being ambulator y immediately before retransplantation (p = 0.04) were associated with survival. By multivariate Cox analysis, being ambulatory before retra nsplantation was the most significant predictor of survival (p = 0.008 ), followed by reoperation in Europe (p = 0.044). Complete pulmonary f unction tests were done yearly in every survivor of retransplantation and bronchiolitis obliterans syndrome stages were assigned. Eleven per cent of patients were in stage 3 at 1 year, 20% at 2 years, and 25% at 3 years after retransplantation. Values of forced expiratory volume i n 1 second decreased from 1.89 +/- 0.13 L early after retransplantatio n to 1.80 +/- 0.15 L at 1 year and 1.54 +/- 0.16 L at 2 years (p = 0.0 06, year 2 versus baseline postoperative value). Most of this decrease occurred in patients who underwent retransplantation because of oblit erative bronchiolitis, whereas the pulmonary function of patients who underwent retransplantation because of other conditions did not signif icantly change. We conclude that survival after pulmonary retransplant ation is improving. Optimal results can be obtained in patients who ar e ambulatory before retransplantation. Compared with recent data after primary lung transplantation, bronchiolitis obliterans syndrome does not appear to recur in an accelerated manner after retransplantation. As long as early mortality as a result of infection can be minimized, pulmonary retransplantation appears to offer a reasonable option in hi ghly selected patients.