Survival of patients with advanced chronic lung allograft dysfunction and the role of redo transplantation.

Background: Lung transplantation (LTx) is a treatment option for end-stage lung disease. Chronic lung allograft dysfunction (CLAD) poses challenges to long-term survival. CLAD is usually progressive with a poor prognosis and limited treatment options. Advanced CLAD is the most common indication for redo lung transplantation (LRT). Decision-making on LRT varies between centers. Methods: This study aimed to explore key aspects of advanced CLAD management, with a focus on disparities in redo transplantation referral and listing rates. A retrospective cohort study was conducted across follow-up clinics at 2 major European centers, examining patient characteristics, treatment approaches, clinical outcomes, and prognostic factors in individuals with advanced CLAD. Results: In a cohort of 177 patients with advanced CLAD, bronchiolitis obliterans syndrome was the predominant phenotype (66%). Significant morbidity was observed, with 66% of patients severely disabled and 49% on oxygen therapy. Over a median follow-up of 568 days, 94 patients died, with a 2-year survival rate of only 25%. LRT was pursued in 72 patients, with 31 undergoing the procedure. Post-LRT mortality was high (48%), particularly in patients requiring advanced respiratory support. Key risk factors for mortality included restrictive or mixed CLAD phenotypes (hazard ratio [HR] 2.759), rapid disease progression (HR 49.671), and urgent LRT (HR 0.026). Conclusions: Advanced CLAD patients face high morbidity and mortality. Redo transplantation seems to offer survival benefit in elective patients. Early referral for redo transplantation and proactive management strategies are essential for improving patient outcomes.