Outcomes after lung retransplantation for restrictive allograft syndrome have not improved over 2 decades.

OBJECTIVE: In 2015, restrictive allograft syndrome (RAS) was first definitively associated with poorer outcomes after lung retransplantation compared with bronchiolitis obliterans syndrome (BOS). This study aimed to evaluate how strategies and outcomes of lung retransplantation for RAS have evolved over time. METHODS: The United Network for Organ Sharing database was queried to identify adult lung retransplants for RAS between 2005 and 2025. Primary transplants, multiorgan transplants, and retransplants with unknown indications were excluded. Patients were stratified into Era 1 (2005-2015) and Era 2 (2016-2025). The primary outcome was 5-year survival. RESULTS: A total of 293 patients were included, with 141 (48%) in Era 1 and 152 (52%) in Era 2. The proportion of retransplants for restrictive disease was similar across eras (19% vs 22%, P = .16). Compared with Era 1, patients from Era 2 had greater allocation scores, less preoperative ventilator dependence, and similar waitlist times. Retransplants in Era 2 were characterized by longer ischemia times and a significantly greater use of bilateral retransplantation (65% vs 41%, P < .001). Postoperatively, patients in Era 2 required more prolonged mechanical ventilation, inhaled nitric oxide, and extracorporeal membrane oxygenation support. Thirty- and 90-day mortality were similar between eras. On multivariable analysis, era of retransplantation was not associated with improved 5-year survival (adjusted hazard ratio, 0.98; 95% CI, 0.70-1.38, P = .93). CONCLUSIONS: Since 2015, lung retransplantation for RAS has increasingly favored bilateral procedures, accompanied by greater perioperative support. Despite these changes, long-term survival remains poor, underscoring the need for improved candidate selection and strategies to prevent recurrent chronic allograft injury.