Is the Third Time the Charm? Evaluating Rehabilitation Differences in Third Lung Transplant Recipients
Purpose Chronic lung allograft dysfunction (CLAD) is the leading cause of graft failure causing significant morbidity and mortality. Re-transplantation (L2Tx) after CLAD is historically associated with complicated peri-operative and post-operative courses, but outcomes have improved as centers gain experience. Third lung transplantation (L3Tx) cases are increasing but functional outcomes are unclear. This study evaluates the overall response to outpatient rehabilitation in patients who underwent L3Tx compared to first-time lung transplant (L1Tx) and L2Tx. Methods This was a secondary analysis of a single-center retrospective cohort. All patients who underwent L3Tx at Duke University Hospital prior to November 1, 2021 were included. L1Tx and L2Tx comparison patients were matched at a ratio of 1:2 and 1:1 respectively based on age at transplant, disease group, and lung allocation score. Pre- and post-transplant rehabilitation scores for Six-Minute Walk Test (6MWT), Shortness of Breath Questionnaire (SOBQ), and Short Physical Performance Battery (SPPB) were analyzed for group comparison. Baseline characteristics and rehabilitation outcomes were compared using Kruskal-Wallis with Dunn’s multiple comparison tests, ANOVA, and Student’s t-test for continuous variables based on normality and Fisher’s exact and Chi-squared tests for categorical variables. Results L3Tx recipients (N=8) were compared to L2Tx (N=8) and L1Tx (N=16) comparison groups. At transplant, groups differed by race, lung disease etiology, PRA Class II %, and BMI. The L3Tx group had significant improvement in 6MWT (mean (SD): 1120 (273) vs. 1770 (478) feet, p = .01) and SOBQ (mean (SD): 71 (13.1) vs 16.6 (12.2), p < .001) scores, but not SPPB (median (SD): 12 (1.46) vs 12 (0.95), p = .95) comparing pre- and post-transplant rehabilitation. No significant difference was noted between L1Tx, L2Tx, and L3Tx groups for changes in 6MWT, SOBQ, or SPPB pre and post lung transplantation. Conclusions In a carefully selected population, L3Tx recipients experience similar improvement post-transplant in 6MWT and SOBQ scores comparable to L1Tx and L2Tx counterparts. Our data also suggests that there is no inherent deficiency in rehabilitation efforts compared to patients who undergo L1Tx or L2Tx. Further studies are required to identify differences in peri-operative outcomes to better inform L3Tx strategies.
