title: Pulmonary retransplantation in the Nordic countries.
abstract: BACKGROUND
  The increasing demand for pulmonary retransplantation (re-LTx) raises ethical issues on the correct allocation of the scarce donor pool. Thus, we performed a thorough review of the current results for re-LTx in the Nordic countries.
  
  
  METHODS
  Seventy-five patients with a median age of 50 years (range, 22 to 64 years) underwent re-LTx from 1992 until June 2013, of which 53 had single re-LTx, 21 had double re-LTx, and 1 patient underwent a heart-lung retransplantation. Primary graft dysfunction (PGD) was the primary indication in 9 cases, bronchiolitis obliterans syndrome (BOS) in 62 cases, and airway complications in 4 cases.
  
  
  RESULTS
  Patients who underwent re-LTx in the period 1992 to 1999 (n = 16) had a 1-year survival of 37.5% (95% confidence interval [CI], 19.9 to 70.6), whereas patients who underwent re-LTx in the period 2000 to 2013 (n = 64) had a 1-year survival of 81.0% (95% CI, 71.5 to 91.8). Corresponding 5-year survival was 25.0% (95% CI, 10.7 to 58.4) in the early era group (1992 to 1999) and 57.2% (95% CI, 44.3 to 73.7) in the more recent era group (2000 to 2013; p = 0.0151). Patients with BOS who underwent re-LTx in the period 1992 to 1999 (n = 13) had a 1-year survival of 38.5% (95% CI, 19.3 to 76.5), whereas patients with BOS who underwent re-LTx in the period 2000 to 2013 (n = 49) had a 1-year survival of 85.4% (95% CI, 75.9 to 96.0). Corresponding 5-year survival was 23.1% (95% CI, 8.6 to 62.3) in the early era group (1992 to 1999) and 56.1% (95% CI, 41.9 to 75.2) in the more recent era group (2000 to 2013; p = 0.0199). The cumulative incidence among patients who underwent re-LTx because of BOS and developed BOS again after re-LTX was analyzed. The cumulative incidence curves for time periods 1992 to 1999 and 2000 to 2013 are not statistically different for repeat BOS (p = 0.5087), but they are highly significant for time periods among patients who died (p = 0.02381).
  
  
  CONCLUSIONS
  Results for re-LTx have improved over time, especially when BOS is the primary indication. The cumulative incidence among patients who underwent re-LTx because of BOS and developed repeat BOS after re-LTX showed equal risk between 1992 to 1999 and 2000 to 2013 in the aspect of developing repeat BOS, but in the later era the patients had a significantly higher chance of surviving.
authors.affiliation: Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Sweden.
authors.forename: Sandra
authors.initials: S
authors.lastname: Lindstedt
authors.affiliation: Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
authors.forename: Göran
authors.initials: G
authors.lastname: Dellgren
authors.affiliation: Department of Pulmonary Medicine, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Martin
authors.initials: M
authors.lastname: Iversen
authors.affiliation: Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
authors.forename: Gerdt C
authors.initials: GC
authors.lastname: Riise
authors.affiliation: Department of Pulmonary Medicine, Rikshospitalet, Oslo, Norway.
authors.forename: Øystein
authors.initials: Ø
authors.lastname: Bjørtuft
authors.affiliation: Department of Cardiac Surgery, Helsinki University Hospital, Helsinki, Finland.
authors.forename: Pekka
authors.initials: P
authors.lastname: Hämmäinen
authors.affiliation: Department of Pulmonary Medicine, Skåne University Hospital, Lund University, Sweden.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Skog
authors.affiliation: Department of Cardiothoracic Surgery, Rikshospitalet, Oslo, Norway.
authors.forename: Arnt
authors.initials: A
authors.lastname: Fiane
authors.affiliation: Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Sweden. Electronic address: per.wierup@skane.se.
authors.forename: Per
authors.initials: P
authors.lastname: Wierup
mesh_terms: D000328:Adult; D001989:Bronchiolitis Obliterans / Q000401:mortality / Q000601:surgery*; D005260:Female; D006085:Graft Survival; D006801:Humans; D016040:Lung Transplantation / Q000401:mortality / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D055031:Primary Graft Dysfunction / Q000401:mortality / Q000601:surgery*; D012086:Reoperation / Q000401:mortality / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012537:Scandinavian and Nordic Countries; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult