Pediatric Repeat Lung Transplantation: A Contemporary Analysis of Trends and Outcomes

Repeat lung transplant (re-LTx) is the only life-saving treatment option for those with irreversible allograft failure. Using a multi-institutional registry database, we investigated the prevalence and outcomes of pediatric re-LTx over the past 35 years.

A retrospective analysis was performed using the Scientific Registry of Transplant Recipients (SRTR). First-time and repeat pediatric LTx candidates from 1989 to 2024 were identified. Univariate analyses, multivariable Cox regression, and Kaplan-Meier plots were performed for a comprehensive analysis.

We identified 1396 primary LTx and 81 re-LTx recipients. The transplant-free survival rates for the primary and re-LTx groups were 80% versus 65% at 1-year (p = 0.004). Re-LTx was a risk factor for worse 1-year post-LTx outcomes (HR 1.82; 95% CI 1.19, 2.8; p = 0.006). The days between primary and re-LTx (< 1 year vs. > 1 year) did not have a statistically significant impact on 1-year post-re-LTx outcomes (HR 0.78; 95% CI 0.28, 2.13; p = 0.63). Those requiring mechanical ventilation (MV) at the time of re-LTx had worse outcomes (HR 2.26; 95% CI 1.14, 4.45; p = 0.02). Unlike children following primary LTx, there was no significant improvement in outcomes over time in children with re-LTx (HR 1.04; 95% CI 0.41, 2.61; p = 0.94 for transplant era 2013-2024 vs. 1989-2000).

Clinical outcomes for pediatric re-LTx over the past 35 years in the United States remain significantly inferior compared to those for primary LTx. Given these findings, pediatric re-LTx should carefully be considered and restricted to judiciously selected candidates, ideally prior to the development of MV requirement.