Lung transplantation is a recognized treatment for end-stage lung disease for selected patients for whom no other options are available ( ). Since the introduction of calcineurin inhibitors in the 1980’s, lung transplantation became a reasonable treatment with improved outcomes ( ). However, chronic rejection or chronic lung allograft dysfunction (CLAD) remains the major limitation for long-term survival ( , ), accounting for more than 40% of deaths beyond the first year after pulmonary transplantation ( ). CLAD leads to a progressive and irreversible loss of function of the transplanted organ. Two important phenotypes have been characterized: Bronchiolitis obliterans Syndrome (BOS), which was already described early in the history of thoracic transplantation ( ) and the first guidelines for diagnosis and staging were published in 1993 ( ). In 2011, Sato . reported another form of CLAD, known as restrictive allograft syndrome (RAS) ( ). During the last decades research has led to a better understanding of the pathophysiological mechanisms leading to CLAD. The classification, the diagnostic criteria and the management of CLAD were recently updated, illustrating the advances in the field ( ). Although some medical treatments or other strategies have potentially demonstrated usefulness either to prevent (for instance azithromycin) or to stabilize CLAD (extracorporeal photophoresis, total lymphoid irradiation) ( ), BOS and RAS remain impossible to cure by using these interventions. In general pulmonary function decline is progressive despite all interventions, leading to increased symptoms and disability, chronic respiratory failure and finally death. Therefore, redo transplantation has so far been considered as the only possible treatment option in a selected cohort of these desperate patients ( , ). Concomitantly, ethical issues arose, related to redo transplantation with potentially worse outcomes in an era of shortage of donor lungs ( ).
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