Dr. CF Wong

 

Introduction

Since the first successful clinical lung transplant in the early 80’s, this procedure has evolved greatly over the past 2 decades and now it has been a well-accepted therapeutic intervention for patients with advanced pulmonary or pulmonary vascular diseases. Over the past years, there has been an increase in the number of transplants performed worldwide and the improvement in outcome was evident. From the registry of International Society of Heart and Lung Transplantation ( ISHLT ), there have been over 20,000 lung transplants performed worldwide and about 2,000 cases done annually.

   

Lung Transplant in Hong Kong

In Hong Kong, lung transplant programme was launched in 1994 in Grantham Hospital and the first lung transplant was performed in 1995. It was a single lung transplant. In the same year, the first heart-lung transplant was also performed. In 1997, the first double lung transplant ( sequential single lung transplant ) was performed.

 

The selection criteria for potential recipients for lung transplant were largely based on the guidelines published by ISHLT. However, due to the limitation in resources, donor organs and experience, the age limits were set at 5 years younger than those in the western guidelines ( for single-lung transplant: 60; double-lung transplant: 55; heart-lung transplant: 50 ), and lung transplants for paediatric patients or from living donors have not been considered. All potential cadaveric lung donors were assessed by lung transplant physician for suitability for transplant with criteria largely based on the ISHLT criteria for ideal cadaveric lung donors.

 

As in December 2007, the programme had received 99 referrals for assessment for transplant. Thirty-seven (37%) patients had been put on waiting list for transplant after assessment.  There have been 15 (2 single-lung, 11 double-lung and 2 heart-lung) transplants performed. The recipients’ underlying diagnoses were: lymphangioleiomyomatosis (4), emphysema (3), bronchiectasis (2), Eisenmenger Syndrome (2), idiopathic pulmonary hypertension (1), Histiocytosis X (1) and obliterative bronchiolitis (1). Common post-transplant complications included bleeding, anastomosis problems, acute rejections, chronic rejections, renal dysfunction, hyperlipidaemia and opportunistic infection by fungi and viruses.  We had also encountered and managed a few rare problems, namely hyper-acute rejection, severe reperfusion injury, graft-versus-host disease, multi-drug resistant tuberculosis and delayed sternotomy infection by Paecilomyces in our transplant recipients. Among these 15 patients, four had died. For lung transplant patients, the survival rates were 100%, 100% and 77.8% at 1, 3 and 5 years respectively. For the 2 heart-lung transplant patients, one died at 6 weeks post-transplant and the other is surviving at 6 years with normal cardiac and lung function. Among the surviving patients, all except one are enjoying satisfactory lung functions and are fully independent in their activities of daily living.

 

Although the lung transplant programme has been operating for almost 15 years, it remained a very small one in terms of referrals, patients listed and the number of transplants performed. As in other solid organ transplant programmes, the most important obstacle is the scarcity of suitable donor organs.  Another important limitation that is inherent in the lung transplant programme in Hong Kong is the respiratory disease pattern in the locality with the extremely low incidence of cystic fibrosis and alpha-1 anti-trypsin deficiency and the high prevalence of tuberculosis and viral hepatitis.

 

Because of the small case volume, our experience is still very limited. However, we could manage to achieve a very good patient outcome with survival comparable to the international experience.

  

Relocation of the Lung Transplant Programme to Queen Mary Hospital

Because of restructuring of service provision of the Hong Kong West Cluster, the Cardiothoracic Surgical Unit together with Cardiothoracic Anaesthesia Unit and the Surgical Intensive Care Unit would be relocated to Queen Mary Hospital in summer this year. Following this move, it has also been decided that the Lung Transplant Programme would be relocated from Grantham Hospital to QMH. With the relocation to a major hospital with easy availability of support from various disciplines, it is hoped that there could be improvement in the delivery of care to our patients.  Also, it might provide opportunities for sharing of experiences and collaboration between our programme and other organ transplant programmes in QMH to explore the possibilities of new ventures like multi-organ transplant for patient with potential indications.

 

Demographics, clinical data and outcome of lung and heart-lung transplant recipients

  

Patient

Sex / Age at Transplant

Year of Transplant

Diagnosis

Waiting time (months)

Type of Transplant

Death/survive 

( Dec 2007 )

1

F / 27

1995

LAM

6

SLT

Died in 2000

2

F/37

1995

VSD Eisenmenger Syndrome

2

HLT

Died in 1996

3

F/33

1997

Bronchiectasis

1

DLT

Died in 2004

4

F / 37

1998

LAM

18

SLT

Survive

5

F / 35

1999

LAM

6

DLT

Survive

6

F / 36

1999

Tuberous sclerosis

5

DLT

Survive

7

M / 53

2001

Emphysema

3

DLT

Survive

8

F/42

2002

VSD Eisenmenger syndrome

5

HLT

Survive

9

M / 48

2002

Histiocytosis X

4

DLT

Survive

10

F / 45

2002

Primary pulmonary hypertension

11

DLT

Survive

11

M / 50

2002

Emphysema

23

DLT

Died in 2005

12

M / 34

2005

Bronchiectasis

19

DLT

Survive

13

M /55

2005

Emphysema

20

DLT

Survive

14

M / 30

2006

Post bone marrow transplant obliterative bronchiolitis

12

DLT

Survive

15

F/41

2007

LAM

18

DLT

Survive

LAM: lymphangioleiomyomatosis; SLT: single-lung transplant; DLT: double-lung transplant; HLT: heart-lung transplant