Redo Lung Transplantation Research Articles

The effect of allograft ischemic time on outcomes following bilateral, single, and reoperative lung transplantation

ObjectiveTo determine whether allograft ischemic times affect outcomes following bilateral, single, and redo lung transplantation. MethodsA nationwide cohort of lung transplant recipients from 2005 through 2020 was examined using the Organ Procurement and Transplantation Network registry. The effects of standard (<6 hours) and extended (≥6 hours) ischemic times on outcomes following primary bilateral (n = 19,624), primary single (n = 688), redo bilateral (n = 8461), and redo single (n = 449) lung transplantation were analyzed. A priori subgroup analysis was performed in the primary and redo bilateral-lung transplant cohorts by further stratifying the extended ischemic time group into mild (≥6 and <8 hours), moderate (≥8 and <10 hours), and long (≥10 hours) subgroups. Primary outcomes included 30-day mortality, 1-year mortality, intubation at 72 hours' posttransplant, extracorporeal membrane oxygenation (ECMO) support at 72 hours' posttransplant, and a composite variable of intubation or ECMO at 72 hours' posttransplant. Secondary outcomes included acute rejection, postoperative dialysis, and hospital length of stay. ResultsRecipients of allografts with ischemic times ≥6 hours experienced increased 30-day and 1-year mortality following primary bilateral-lung transplantation, but increased mortality was not observed following primary single, redo bilateral, or redo single-lung transplants. Extended ischemic times correlated with prolonged intubation or increased postoperative ECMO support in the primary bilateral, primary single, and redo bilateral-lung transplant cohorts but did not affect these outcomes following redo single-lung transplantation. ConclusionsSince prolonged allograft ischemia correlates with worse transplant outcomes, the decision to use donor lungs with extended ischemic times must consider the specific benefits and risks associated with individual recipient factors and institutional expertise.

(661) Acrophialophora Anastomotic Site Infection in a Re-Do Lung Transplant Recipient with Cystic Fibrosis

(661) Acrophialophora Anastomotic Site Infection in a Re-Do Lung Transplant Recipient with Cystic Fibrosis

Time since primary transplant and poor functional status predict survival after redo lung transplant.

In previous studies, lower functional status measured by Karnofsky Performance Status (KPS) correlated with worse survival after redo lung transplant. We hypothesize that combining reduced functional status and time from primary lung transplant will correlate with the etiology of lung allograft failure after primary lung transplant and more accurately predict survival after redo lung transplant. This retrospective study was approved by University of Minnesota Institutional Review Board. From the Scientific Registry of Transplant Recipients (SRTR) database, 739 patients underwent redo lung transplant (01/01/2005-8/30/2019). Pre-lung transplant characteristics, KPS, time between primary and redo lung transplant, outcomes, overall survival were evaluated. Paired comparisons were used to compare pre-transplant variables. A Cox regression model was fit to examine re-transplant survival. Due to non-proportional hazards, time between transplants was split into <1-year vs. 1+ years and analyzed with time-dependent coefficients, with follow-up time considered in three segments (0-6, 6-24, 24+ months). After KPS grouping (10-40%, 50-70%, 80-100%), KPS 10-40% were less likely to be discharged after primary transplant and more likely required mechanical ventilation or extracorporeal membrane oxygenation (ECMO) bridging (P<0.001). Redo lung transplant survival was worse in the KPS 10-40% group who more likely underwent lung transplant <1 year after primary lung transplant. Mortality was significantly higher for patients who underwent redo lung transplant within one year of primary transplant when KPS was 10-40% (P<0.001). These patients were more likely to require redo lung transplant due to primary graft failure or acute cellular rejection. Functional status and time from primary lung transplant are strong predictors of outcome after redo lung transplant. We categorized redo lung transplant recipients in two distinct groups. One group has early allograft failure and poor functional status with a very poor prognosis after redo lung transplant. The other group has chronic allograft failure and overall better functional status with relatively better survival after redo lung transplant. Salvage redo lung transplant for primary allograft failure or acute rejection is associated with low one year survival.

Risk Factors and Outcomes of Postoperative Hepatic Dysfunction After Lung Transplantation

BackgroundHepatic dysfunction is a morbid complication of lung transplantation. Little is known about risk factors for postoperative hepatic dysfunction or its impact on survival after lung transplantation. MethodsThis retrospective analysis of 1406 adult lung transplant recipients was performed at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania between January 1, 2007 and December 1, 2019. Patients were excluded for redo lung transplantation, concomitant cardiac surgery, or concurrent solid organ transplantation. Postoperative liver dysfunction was classified as either ischemic liver injury or nonischemic dysfunction (transaminitis, hyperbilirubinemia). ResultsAmong the 1155 primary lung transplant recipients included, postoperative hepatic dysfunction developed in 96 (8.3%) after lung transplantation. A history of liver disease was the greatest predictor of postoperative hepatic dysfunction (odds ratio, 6.19; CI, 2.13-17.4; P < .001). Patients with postoperative hepatic dysfunction had a greater need for intraoperative blood products (ischemic, 12 U [range, 6-21 U]; nonischemic, 10 U [range, 4-28 U]; vs none, 4 U [range, 1-12 U]; P < .001) and an increased need for postoperative circulatory support (ischemic, 16 [76%]; nonischemic, 25 [33%]; none, 117 [11%]; P < .001). Both ischemic liver injury and nonischemic dysfunction were associated with diminished 1-, 3-, and 5-year term survival (ischemic, 27.5%, 16.5%, and 0%, respectively; nonischemic, 60%, 49.6%, and 46.9%, respectively; none, 87.3%, 72.3%, and 59.5%, respectively; P < .001). ConclusionsHepatic dysfunction after lung transplantation is associated with significant morbidity and mortality. A history of liver disease was the best positive predictor for postoperative dysfunction. Additional studies are necessary to identify the best treatment algorithm to avoid hepatic dysfunction more effectively in the postoperative setting after lung transplantation.

Bridge Using the Hemolung System for Re-Do Double Lung Transplant In Situs Inversus Patient

IntroductionExtracorporeal life support (ECLS) use in redo-lung transplant is limited due to poor outcomes. Extracorporeal circulation with a single cannula provides the advantage of mobility and effective rehabilitationn in patients with an expected long run. The Hemolung veno-venous extracorporeal carbon dioxide removal (ECCO2R) system allows for adequate removal of carbon dioxide with a small French double lumen catheter.Case ReportA 29-year-old female with Kartagener syndrome and complete situs inversus underwent a double lung transplant for end stage lung disease. Her postoperative course was uneventful. After an aspiration event, she experienced a severe and persistent decline in her lung function within her first year. She ultimately was hospitalized requiring mechanical ventilation and a tracheostomy. The patient had primarily hypercapnic respiratory failure with radiographic signs of CLAD. The need for a high respiratory rate led to increased calory consumption with a significant impact on her BMI. To optimize her nutritional status and muscle strength before re-do lung transplantation, we decided to bridge her with ECLS. The use of an Avalon cannula was limited by her anatomy as the outflow jet will point against the atrial wall. Dual site cannulation was deemed suboptimal to preserve mobility. We decided to proceed with a Hemolung after emergency FDA authorization. A dual-lumen 15.5Fr catheter was placed via the left IJ into the superior vena cava. As we normalized her CO2 by active ECCO2R removal, we were able to reduce her ventilatory needs, improve her nutritional status and mobility. She was listed and underwent an uneventful redo-double lung transplant with cardiopulmonary support. The patient is 200 days out and doing well.SummaryThis experience demonstrates that ECCO2R technologies can be safely and effectively used to bridge lung transplant patients with hypercapnic respiratory failure in which anatomical challenges limit cannulation options. Extracorporeal life support (ECLS) use in redo-lung transplant is limited due to poor outcomes. Extracorporeal circulation with a single cannula provides the advantage of mobility and effective rehabilitationn in patients with an expected long run. The Hemolung veno-venous extracorporeal carbon dioxide removal (ECCO2R) system allows for adequate removal of carbon dioxide with a small French double lumen catheter. A 29-year-old female with Kartagener syndrome and complete situs inversus underwent a double lung transplant for end stage lung disease. Her postoperative course was uneventful. After an aspiration event, she experienced a severe and persistent decline in her lung function within her first year. She ultimately was hospitalized requiring mechanical ventilation and a tracheostomy. The patient had primarily hypercapnic respiratory failure with radiographic signs of CLAD. The need for a high respiratory rate led to increased calory consumption with a significant impact on her BMI. To optimize her nutritional status and muscle strength before re-do lung transplantation, we decided to bridge her with ECLS. The use of an Avalon cannula was limited by her anatomy as the outflow jet will point against the atrial wall. Dual site cannulation was deemed suboptimal to preserve mobility. We decided to proceed with a Hemolung after emergency FDA authorization. A dual-lumen 15.5Fr catheter was placed via the left IJ into the superior vena cava. As we normalized her CO2 by active ECCO2R removal, we were able to reduce her ventilatory needs, improve her nutritional status and mobility. She was listed and underwent an uneventful redo-double lung transplant with cardiopulmonary support. The patient is 200 days out and doing well. This experience demonstrates that ECCO2R technologies can be safely and effectively used to bridge lung transplant patients with hypercapnic respiratory failure in which anatomical challenges limit cannulation options.

Sequential Redo Bilateral Lung Transplantation in a Patient with a Prior Heart-Lung Transplantation with Tracheal Anastomosis

<h3>Introduction</h3> Redo lung transplantation (LT) for chronic lung allograft dysfunction (CLAD) is technically complex. We present a redo bilateral LT after previous heart-lung transplantation (HLT) with salvage of tracheal anastomosis and donor-to-donor main bronchi anastomoses. <h3>Case Report</h3> Patient is a 22-year-old male with previous HLT 17 years prior for pulmonary arterial hypertension now with preserved cardiac function, CLAD (FEV1 36%) with chronic hypercapnic respiratory failure, and pulmonary fungal infection with multidrug resistant <i>Lomentospora prolificans</i>. Prior to listing sputum culture was negative for fungal growth. His LAS was 45.8, and he spent 36 days on the wait list prior to a suitable donor being identified. Surgical approach involved redo clamshell thoracotomy. To control for possible fungal dissemination both lungs were explanted simultaneously under cardiopulmonary bypass, and extensive irrigation of chest cavities and trachea was completed with amphotericin B and caspofungin. The prior tracheal anastomosis was left intact. Pump suction and cell salvage was avoided. Standard sequential implantation with donor-to-donor main bronchi anastomoses was completed. Lung explant pathology demonstrated active subtotal and total bronchiolitis obliterans (C1) associated and necrotizing and non-necrotizing granulomas. Primary graft dysfunction was grade 1 at time 0, 24, 48, and 72 hrs. Postoperative antifungal regimen was Olorofim, caspofungin, and inhaled amphotericin B. No short-term airway complications were encountered. First transbronchial biopsy (TBBx) demonstrated moderate acute cellular rejection (ACR; A3B2), and <i>Lomentospora prolificans</i> growth. Due to persistent fungal growth, but no evidence of fungal pneumonia on chest imaging, systemic antifungal regimen was adjusted to fosmanogepix, miltefosine, posaconazole, and caspofungin. After 5 days of new antifungal regimen, 500 mg methylprednisone x 3 days was administered for ACR. Patient was discharged home on POD32. Second TBBx demonstrated no ACR but fungal elements persisted. <h3>Summary</h3> Redo bilateral LT after HLT with salvage of tracheal anastomosis and donor-to-donor main bronchial anastomosis is feasible without airway complications. Antifungal regimen will continue with re-evaluation at 6 months postoperatively.

Impact of Gender and Age at Lung Transplantation on Long-Term Survival of Patients with Cystic Fibrosis

<h3>Purpose</h3> Cystic fibrosis (CF) is caused by mutations in the CF transmembrane conductance regulator; these mutations impair chloride conduction, which reduces water on the cell surface and leads to accumulation of viscous mucous in the lungs. Accumulated mucous drives chronic infections, bronchiectasis, and eventually, respiratory failure requiring lung transplant (LT). We aimed to study the impact of gender and age at the time of LT on long-term survival of patients with CF. <h3>Methods</h3> Lung transplant recipients with CF who received post-LT care at our center between July 1, 2007 and April 30, 2021 were included. Primary outcome was death or redo LT. Cox proportional hazard analysis, Kaplan-Meier method, and log-rank tests were used for data analysis. <h3>Results</h3> A total of 59 LT recipients met inclusion criteria. The median age at primary LT was 28 (22, 36) years, 36 (61%) patients were ≥25 years old, and 30 (51%) were male. At the end of the study period, 21 (35.6%) LT recipients died and 17 (28.8%) required redo LT with a median lung allograft survival of 33.4 (16.1, 66.4) months. The remaining 21 patients (36%) were alive at a median of 68 (28, 112) months after primary LT. The risk of death trended lower and the probability of survival trended higher in male patients than in female patients (HR: 0.487 [95% CI: 0.221-1.075], p=0.075 and 66.7% vs 44.8%, p=0.069, respectively, Figure 1A). Compared to age <25 years at LT, age ≥25 years was associated with a lower risk of death and an increased probability of survival (HR: 0.466 [95% CI: 0.215-1.007], p=0.052 and 63.9% vs 43.5%, p=0.047, respectively, Figure 1B). <h3>Conclusion</h3> In our study, LT recipients with CF ≥25 years at LT had significantly higher survival than younger patients, and survival trended higher for male recipients than female recipients. These results identify an "at-risk" population of LT recipients who may warrant closer attention after LT. Large multicenter trials with adequate power are needed.

Outcome of Redo Transplantation Compared to First Lung Transplantation in a Cystic Fibrosis Cohort

<h3>Purpose</h3> Improve of long-term survival after lung transplantation have increase the number of chronic rejections, especially in cystic fibrosis, usually young at the time of the first lung transplantation. They present the same systemic disease but with a new end-stage lung disease. <h3>Methods</h3> After ethical approval, we retrospectively collected the perioperative data of cystic fibrosis patients who underwent primary lung transplantation (LgTx group) or redo transplantation (RedoLgTx group) from January 2012 to June 2021. We aimed to compared perioperative data and outcome up to first hospital discharge. Results are presented as number (percentage) and median and were compared using Chi-square or Fischer test and, Mann Whitney Wilcoxon test. <h3>Results</h3> A total of 280 patients were included in the study: 257 in the LgTx group and 23 in the RedoLgTx group. There were no statistical difference between groups concerning 90-days survival (Log Rank; p=0.114), neither concerning early postoperative outcome (table 1). Demographic characteristics were not significantly different. In the RedoLgTx group, 2nd graft ischemia duration (494min vs. 422min; p=0.02), fluid support (2.8L vs 3.7L; p=0.003) and lactatemia at the end of the surgery (2.8mmol/L vs 4.2mmol/L; p=0.01) were higher. However, intraoperative ECMO requirement (45.7% vs 47.8%; p=0.84) and blood loss (1.5L vs. 1L; p=0.07) were not statistically different between groups. <h3>Conclusion</h3> Early outcome after redo lung transplantation for cystic fibrosis did not appeared to be more perjorative than first transplantation, even though surgery was more complex.

Phenotypical Characterization of Airway Morphology in Post-Infectious vs Post-Lung Transplantation Bronchiolitis Obliterans

Purpose Post-infectious bronchiolitis obliterans (PIBO) forms a chronic obstructive lung disease in children following a severe viral respiratory infection. Subsequent dysanaptic lung growth, with differential development of the alveolar compartment over the airway compartment, was clinically described, but remains elusive. We therefore performed a detailed 3D airway characterization in PIBO compared to bronchiolitis obliterans syndrome (BOS) after lung transplantation and discarded donor lungs. Methods Explant lungs from matched adult patients who underwent lung transplantation for end-stage PIBO (n=5), redo lung transplantation patients with end-stage BOS (n=5), and discarded donor lungs (n=5) were included. Lungs were air-inflated and frozen in fumes of liquid nitrogen. Ex vivo computed tomography (CT) scans (resolution 700 µm) were obtained and used for radiologic scoring and semi-automated 3D airway segmentation. Next, frozen lungs were sampled on matched locations (n=4/lung) and scanned with microCT (resolution 10 µm). Results Radiologic scoring indicated more airway wall thickening (p=0.079), bronchial dilatation (p=0.087), and pleural thickening (p=0.071) in PIBO vs BOS. The number of airways per generation was similar between groups (p=0.53), but airway diameters were increased in PIBO (generation 6-11) and in BOS lungs (generation 7-10) compared to controls, without differences between PIBO and BOS. Significantly more airways ended in BO lesions in BOS vs PIBO (p=0.016, mean 25.60% vs 12.60%), although the size of the BO lesions was increased in PIBO vs BOS (p=0.032, median 27.23mm³ vs 5.01mm³). Subsequent micro CT assessment revealed a significant lower number of terminal bronchioles (TB) in PIBO (p=0.0009, PIBO: mean 3131 TB/lung, BOS: 8360 TB/lung, controls: 10342 TB/lung), although diameters of TB were similar across groups (p=0.37). In addition, alveolar spaces tended to be larger in PIBO (p=0.070). 3D micro CT analysis confirmed that in BOS, BO lesions are only segmental with preserved TBs, while in PIBO, the airway is completely lost following the obstruction. Conclusion PIBO lungs displayed a more than two-fold decrease in TB compared to BOS, with fewer but larger BO lesions and non-reopening of airways distal from BO. Our findings provide potential pathophysiologic evidence of dysanaptic lung growth in PIBO.

Functional Status and Time Since Primary Lung Transplant Predict Survival after Redo Lung Transplant

Survival is worse after redo lung transplant (LTx) compared to primary LTx. We hypothesize that functional status and time since primary LTx predict survival after redo LTx. From the Scientific Registry of Transplant Recipients (SRTR) database, 681 adult and pediatric patients underwent primary LTx before redo LTx from 01/01/2005-9/1/2018. Pre-LTx characteristics, Karnofsky Performance Status (KPS), time between primary and redo LTx, intra-operative variables, LTx complications, and survival were evaluated. Those with en bloc, lobar, multivisceral or heart-lung transplants, or without preoperative KPS were excluded. Paired comparisons were used to compare pre-transplant variables. Survival analysis was used to examine mortality after redo LTx, and risk factors for survival within a Cox PH regression model including recipient center as a random effect, while time between transplants was considered using time-dependent coefficients at follow-up times of 3, 6, and 12 months. All analysis was performed in R (ver. 3.6.0) RESULTS: KPS was grouped into 3 categories:10-40%, 50-60%, 70-100%. Compared to their first transplant, KPS prior to redo LTx was significantly worse (37% vs 64% with a KPS of 10-40%). Prior to their redo LTx, patients were more likely to require ventilation support (9% vs 37%) and ICU admission (13% vs 37%). Following redo LTx, survival was worse in the KPS 10-40% group, compared to the 50-60% and 70-100% groups (Figure 1, log-rank p=0.017). This effect was lessened in the multivariate model, but survival for the 70-100% group was still better than for KPS 10-40%. The effect of decreased time between transplants is most prominent in the early postoperative period. Higher functional status and increased time between the primary and redo LTx predict improved survival after redo LTx. Increased mortality risk with early redo LTx is most dramatic in the early postoperative period after redo LTx.

Do Long Term Outcomes Justify Third Time Redo Lung Transplantation?

Purpose Graft failure remains a significant obstacle to long-term survival in lung transplantation (LT), however, the reported outcomes of reoperative LT are inferior to primary LT, and there is controversy of how best to manage a scarcity of donor allografts for candidates likely to derive maximum benefit. The outcomes of third-time LT have not been described in detail. Methods Review of UNOS database was performed. 3rd time recipients of LT were identified and compared to first-time and second-time LT recipients. Survival was estimated with Kaplan Meier method and compared using log-rank test. Influence of 2nd and 3rd LT was performed using univariate and multivariate analyses. Results 28 recipients of 3rd LT were compared to 1,252 2nd LT and 32,703 primary recipients. Patients of 3rd LT were younger (38.1 ± 16.0 years vs 44.4 ± 16.8 for 2nd LT, 52.6 ± 14.6 for primary LT), and have shorter wait list times (37.0 days [95% CI 9.0-67.5] vs 45.5 days [13.0-57.5] for 2nd LT and 112.0 [30.0- 329.0] for primary LT. Median survival was 60 months for primary LT, 32 months for 2nd LT, and 19 months for 3rd LT (log-rank p Conclusion Reoperative LT has significantly lower long-term survival compared to primary LT, and survival after 3rd LT appears to be worse than 2rd LT. Further work is needed to define which candidates are likely to benefit most from reoperative LT.

Lung transplant patients with coronary artery disease rarely die of cardiac causes.

A relative contraindication for lung transplant (LT) is coronary disease burden sufficient to cause risk of myocardial infarction after LT. We analyzed cause of death and outcomes of our LT patients with coronary artery disease (CAD). Inpatient records from March 1, 2004, to January 31, 2015, were retrospectively examined and data of 306 LTs extracted. Twenty-five patients without coronary angiography (CA) and 7 with redo LTs were excluded. The other 274 patients were divided into 2 groups: CAD (n=116) and no CAD (n=158). Patients with prior revascularization or coronary stenosis >10% were placed into the CAD group. The CAD group was older and had more male patients, greater history of smoking and hypertension, and greater proportion of patients with interstitial lung disease than the no-CAD group. CAD patients were more likely to receive a single-lung transplant. Death of cardiac causes occurred for 2 patients (1.7%) in the CAD group and for 1 patient (0.6%) in the no-CAD group (P=0.39). This analysis shows that compared with patients who have no CAD, patients with CAD have different demographic characteristics and receive more single-lung transplants. Incidence of death of cardiac causes is rare.

Single and Double Redo Lung Transplantation: A Review of UNOS Data

Single and Double Redo Lung Transplantation: A Review of UNOS Data

Invited Commentary

The current issue of The Annals features an insightful article from Kon and colleagues [1Kon Z.N. Bittle G.J. Pasrija C. Sanchez P.G. Griffith B.P. Pierson R.N. The optimal procedure for retransplantation after single lung transplantation.Ann Thorac Surg. 2017; 104: 170-175Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] from Maryland summarizing the strategies for lung retransplantation after a single lung transplant, their respective outcomes, and potential recommended approaches to early and late allograft failure. Of primary relevance, their data reinforce multiple database reviews that the incidence of lung retransplantation has increased over the past two decades, as late outcomes remain poor—emphasizing the need for an algorithm to manage patients towards successful retransplant. Kon and associates reviewed all single lung transplants (SLTs) from the Organ Procurement Transplant Network between 1994 and 2012. Three hundred twenty-five of these went on to require retransplantation. Redo lung transplant strategies were ipsilateral transplant (ILT, n = 50, 15%), contralateral (CLT, n = 175, 54%), and bilateral (BLT, n = 100, 31%). The indications and demographics were similar across cohorts. Timing of retransplant is essential to appreciate. Re-transplant was early (<30 days from primary SLT) in 26% of the ILTs, 2% of the CLTs, and 20% of the BLTs. Thirty-day, 1-year, and 5-year survivals were equivalent in the BLT (89%, 67%, 42%) and CLT groups (94%, 72%, 41%); both of these were superior to the rates from the ILT cohort (80%, 50%, 20%). These results highlight the known principle that early (<30 day) graft failure portends poor overall survival. Early graft failure implies both the transplanted lung and the native lung are both insufficiently functioning. This cohort often fails from the time of initial surgery and requires ventilator support. Both ILT and ventilator support were markers of poor outcomes in the study by Kon and colleagues. That being said, early failure is often less of a technical burden, with shorter immune-suppression burden, for retransplantation. In these cases, ILT and BLT were the strategies of choice. Both provide the maximum physiological support with less technical tour de force required. Late failure more commonly involves the challenge of scarring of the initial transplanted lung and hilum, and a cumulative impact of immunosuppression. Hence, 98% of CLT transplants were in this setting, avoiding the initially entered hemithorax. The outcomes from the Organ Procurement Transplant Network database that were reviewed were equivalent early and mid-term (5-year) with CLT to BLT. This is less intuitive in the contemporary era where bilateral transplantation is preferred for most all pathology. In the setting of retransplantation, however, limited donor organ resources, and the less-technical challenge of CLT (with similar mid-term outcomes), provide practical strength in this strategy for retransplantation of late graft failure. The Optimal Procedure for Retransplantation After Single Lung TransplantationThe Annals of Thoracic SurgeryVol. 104Issue 1PreviewRetransplantation has emerged as a therapeutic option for patients experiencing respiratory failure after single lung transplantation. However, outcomes associated with the surgical option (ipsilateral, contralateral, or bilateral lung retransplantation) has not been well evaluated. Full-Text PDF

Impact of CLAD Phenotype on Survival After Lung Retransplantation: A Multicenter Study

Chronic lung allograft dysfunction (CLAD) remains a major problem after lung transplantation with no definitive treatment except redo lung transplantation (re-LTx) in selected candidates. However, CLAD is not a homogeneous entity and different phenotypes exist. Therefore, we aimed to evaluate the effect of CLAD phenotypes on survival after re-LTx for CLAD. Patients who underwent re-LTx for respiratory failure secondary to CLAD in four LTx centers between 2003 and 2013 were included in this retrospective analysis. Bronchiolitis obliterans syndrome (BOS) and restrictive CLAD (rCLAD) were distinguished using pulmonary function, radiology and explant lung histopathology. Patient variables pre- and post-re-LTx were collected and analyzed. A total of 143 patients underwent re-LTx for CLAD resulting in 94 BOS (66%) and 49 rCLAD (34%) patients. Unadjusted and adjusted survival after re-LTx for rCLAD was worse compared to BOS (HR = 2.60, 1.59-4.24; p < 0.0001 and HR = 2.61, 1.51-4.51; p = 0.0006, respectively). Patients waiting at home prior to re-LTx experienced better survival compared to hospitalized patients (HR 0.40; 0.23-0.72; p = 0.0022). Patients with rCLAD redeveloped CLAD earlier and were more likely to redevelop rCLAD. Survival after re-LTx for rCLAD is worse compared to BOS. Consequently, re-LTx for rCLAD should be critically discussed, particularly when additional peri-operative risk factors are present.

(670) - Assessment of Human Lungs Recovered From Uncontrolled Donation After Circulatory Determination of Death (uDCDD) Donors By Ex-Vivo Lung Perfusion (EVLP) and CT Scan

s S247 Methods: The UNOS/OPTN database was queried to identify all LKT, LT, and KT performed in the U.S. from 1995-2013. Survival was calculated using the Kaplan-Meier method & compared using log-rank tests or Cox regression models. Results: Thirty-one LKT, including 3 heart-lung-kidney transplants, were performed. Median follow-up was 14.46 months (19 days 8.51 years). The mean age of LKT recipients was 44.8 ± 13.1 years & 48% were male. Redo lung transplant for graft failure was the leading indication for LT (n= 13), followed by cystic fibrosis (n= 4). The most common renal indication was calcineurin inhibitor nephrotoxicity (n= 11). Mean lung allocation score (LAS) was 46.6 ± 14.4. No patient required extracorporeal membrane oxygenation. Mean creatinine was 3.7 ± 2.8 mg/dL, MDRD estimated GFR was 26.1 ± 17.6 mL/min/1.73m2, & 11 patients were dialysis-dependent. Ischemic time for lung & kidney grafts was 4.6 ± 1.7 & 12.6 ± 8.1 hours. Patient survival after LKT was 93%, 71%, & 71% at 1 month, 6 months, & 1 year with median survival 95.2 months. Relative to single-organ transplant, 1 & 5 year survival after LKT, 71% & 60%, were similar to LT (n= 23,913), 82% & 51% (p = 0.061 & 0.55), & inferior to KT (n= 175,269), 95% & 83% (p < 0.0001). Outcomes improved in the LAS era: 1 & 5 year survival for LKT (n= 23) were 78% & 72% & remained similar to LT (n= 12,755), 84% & 53% (p = 0.30 & 0.88). Redo status did not increase mortality after LKT at 1 (HR 1.05, 95% CI [0.28, 3.93] & 4 years (HR 1.18 [0.36, 3.88]), in contrast to significantly increased mortality after LT: HR 1.89 [1.68, 2.14] & HR 1.75 [1.60,1.92]. Conclusion: This is the first study to describe outcomes after lung-kidney transplantation. Patient survival following lung-kidney transplant is similar to lung-only transplant & is an acceptable option for lung-transplant candidates with significant renal dysfunction.

(667) - Frailty Is Associated With Increased Mortality and Hospitalization in COPD

s S247 Methods: The UNOS/OPTN database was queried to identify all LKT, LT, and KT performed in the U.S. from 1995-2013. Survival was calculated using the Kaplan-Meier method & compared using log-rank tests or Cox regression models. Results: Thirty-one LKT, including 3 heart-lung-kidney transplants, were performed. Median follow-up was 14.46 months (19 days 8.51 years). The mean age of LKT recipients was 44.8 ± 13.1 years & 48% were male. Redo lung transplant for graft failure was the leading indication for LT (n= 13), followed by cystic fibrosis (n= 4). The most common renal indication was calcineurin inhibitor nephrotoxicity (n= 11). Mean lung allocation score (LAS) was 46.6 ± 14.4. No patient required extracorporeal membrane oxygenation. Mean creatinine was 3.7 ± 2.8 mg/dL, MDRD estimated GFR was 26.1 ± 17.6 mL/min/1.73m2, & 11 patients were dialysis-dependent. Ischemic time for lung & kidney grafts was 4.6 ± 1.7 & 12.6 ± 8.1 hours. Patient survival after LKT was 93%, 71%, & 71% at 1 month, 6 months, & 1 year with median survival 95.2 months. Relative to single-organ transplant, 1 & 5 year survival after LKT, 71% & 60%, were similar to LT (n= 23,913), 82% & 51% (p = 0.061 & 0.55), & inferior to KT (n= 175,269), 95% & 83% (p < 0.0001). Outcomes improved in the LAS era: 1 & 5 year survival for LKT (n= 23) were 78% & 72% & remained similar to LT (n= 12,755), 84% & 53% (p = 0.30 & 0.88). Redo status did not increase mortality after LKT at 1 (HR 1.05, 95% CI [0.28, 3.93] & 4 years (HR 1.18 [0.36, 3.88]), in contrast to significantly increased mortality after LT: HR 1.89 [1.68, 2.14] & HR 1.75 [1.60,1.92]. Conclusion: This is the first study to describe outcomes after lung-kidney transplantation. Patient survival following lung-kidney transplant is similar to lung-only transplant & is an acceptable option for lung-transplant candidates with significant renal dysfunction.

(668) - 100 Lung Transplants Delivered in Ireland

s S247 Methods: The UNOS/OPTN database was queried to identify all LKT, LT, and KT performed in the U.S. from 1995-2013. Survival was calculated using the Kaplan-Meier method & compared using log-rank tests or Cox regression models. Results: Thirty-one LKT, including 3 heart-lung-kidney transplants, were performed. Median follow-up was 14.46 months (19 days 8.51 years). The mean age of LKT recipients was 44.8 ± 13.1 years & 48% were male. Redo lung transplant for graft failure was the leading indication for LT (n= 13), followed by cystic fibrosis (n= 4). The most common renal indication was calcineurin inhibitor nephrotoxicity (n= 11). Mean lung allocation score (LAS) was 46.6 ± 14.4. No patient required extracorporeal membrane oxygenation. Mean creatinine was 3.7 ± 2.8 mg/dL, MDRD estimated GFR was 26.1 ± 17.6 mL/min/1.73m2, & 11 patients were dialysis-dependent. Ischemic time for lung & kidney grafts was 4.6 ± 1.7 & 12.6 ± 8.1 hours. Patient survival after LKT was 93%, 71%, & 71% at 1 month, 6 months, & 1 year with median survival 95.2 months. Relative to single-organ transplant, 1 & 5 year survival after LKT, 71% & 60%, were similar to LT (n= 23,913), 82% & 51% (p = 0.061 & 0.55), & inferior to KT (n= 175,269), 95% & 83% (p < 0.0001). Outcomes improved in the LAS era: 1 & 5 year survival for LKT (n= 23) were 78% & 72% & remained similar to LT (n= 12,755), 84% & 53% (p = 0.30 & 0.88). Redo status did not increase mortality after LKT at 1 (HR 1.05, 95% CI [0.28, 3.93] & 4 years (HR 1.18 [0.36, 3.88]), in contrast to significantly increased mortality after LT: HR 1.89 [1.68, 2.14] & HR 1.75 [1.60,1.92]. Conclusion: This is the first study to describe outcomes after lung-kidney transplantation. Patient survival following lung-kidney transplant is similar to lung-only transplant & is an acceptable option for lung-transplant candidates with significant renal dysfunction.

(794) - Lung Retransplantation for Early Graft Failure: Trends and Results in 112 Patients Over a 24-Year Period

In this study, we review trends and results of lung retransplantation for early graft failure (EGF) in the United States. Adult patients undergoing lung transplantation between 1987-2010 were identified in the United Network for Organ Sharing database. Patients undergoing redo lung transplantation for EGF (defined as within 90-days of original transplant) were compared to primary lung transplant patients (PLTx) and those undergoing redo lung transplantation for late graft failure (LGF). Trends were identified using three eras (1987-1994, 1995-2004, and 2005-2010). Postoperative complications were also compared between cohorts. Of 20,658 lung transplant recipients in the 24-year study period, 719(3%) were redo transplants (112 EGF, 607 LGF). The mean interval between initial transplant and redo transplant was 18.5±19.2 days for the EGF group and 1502.5±1201.7 days for the LGF group. The EGF cohort had significantly worse overall 1-year survival (49% versus 81% PLTx versus 68% LGF; p<0.001). Although 1-year survival significantly improved over time for the other cohorts (PLTx: 75% to 84%, p<0.001; LGF: 45% to 73%, p<0.001), this was not observed in the EGF patients (48% to 48%, p=0.88). Postoperative rates of renal failure requiring dialysis (31% versus 5% PLTx versus 11% LGF, p<0.001), stroke (5% versus 2% PLTx versus 1% LGF, p=0.05), reoperation (57% versus 19% PLTx versus 24% LGF, p<0.001), and infection (74% versus 44% PLTx versus 57% LGF, p<0.001) were higher in the EGF group. Median days of hospitalization were also longer in EGF (46 versus 24 in PLTx versus 31 in LGF, p<0.001). Redo lung transplant for EGF is associated with significantly high mortality and morbidity risk. Although overall outcomes in lung transplant recipients have improved over the last quarter century, this has not applied to the EGF subset. Judicious patient selection in this challenging cohort remains prudent in the modern era.

Survival Outcomes of Redo Lung Transplantation

Introduction: Redo lung transplantation (redo-LTx) is often the only potentially successful therapeutic option available after graft failure of the primary lung transplant. However questions remain regarding the equity of distribution of donor organs especially given reports of worse survival rates following redo-LTx.