Lower CLAD and Good Survival in Lung Transplant Recipients With Pneumoconiosis: A Spanish National Multicentre Case–Control Study

BACKGROUND AND OBJECTIVE: Pneumoconiosis are irreversible fibrosing pulmonary diseases resulting from the inhalation of inorganic dusts. Lung transplantation (LT) is an option in advanced stages, but evidence on outcomes-especially early postoperative outcomes-remains limited. This national multicentre study evaluates LT outcomes in pneumoconiosis patients, almost all with silicosis. METHODS: A retrospective case-control study was conducted in 7 LT centres in Spain (2010-2023). A total of 81 LT cases due to pneumoconiosis (78 silicosis and 3 coal workers' pneumoconiosis) and 152 controls matched for age, sex, LT type, and LT date were included. Demographic, perioperative, and long-term follow-up variables were recorded. Postoperative complications, survival, and Chronic Lung Allograft Dysfunction (CLAD) were compared between groups. RESULTS: Pneumoconiosis LT recipients (1.77% of LTs performed) had greater surgical complexity, but no differences in immediate postoperative complications, long-term survival, or reinterventions. However, they presented a lower incidence of CLAD (p = 0.007) and a higher proportion of restrictive allograft syndrome (RAS) (p = 0.015) compared to controls. Median survival was 9.1 years (95% CI 4.9-13.2) in the silicosis group and 7.9 years (95% CI 5.2-10.6) in controls (p = 0.839). CONCLUSION: LT in well-selected pneumoconiosis patients, predominantly with silicosis, is a viable alternative with outcomes comparable to other chronic lung diseases. Despite surgical complexity, no differences were identified in postoperative outcomes or survival. The lower CLAD incidence opens new research avenues on underlying immunopathogenic mechanisms.