Lung transplantation in China between 2015 and 2018

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Lung transplantation in China between 2015 and 2018

Each year, around 4,600 lung transplants are performed worldwide, offering a lifeline to patients with end-stage lung disease for whom no other treatments exist. In China, the number of people waiting for a lung transplant has grown steadily—and so has the need to assess how these procedures are performing. A 2019 study using data from the China Lung Transplantation Registry (CLuTR) provides a detailed look at lung transplantation in China between 2015 and 2018, covering everything from why patients need transplants to their long-term survival.

The study was led by Chun-Xiao Hu, Wen-Hui Chen, Jian-Xing He, Ge-Ning Jiang, and colleagues from leading Chinese institutions—including Wuxi Lung Transplant Center, China-Japan Friendship Hospital, and The First Affiliated Hospital of Guangzhou Medical University. It draws on data from 18 registered transplant centers to offer insights into one of the world’s fastest-growing lung transplant programs.

How the Study Was Done

Researchers conducted a retrospective analysis (looking back at existing data) of 1,053 lung transplants performed between January 2015 and December 2018. They examined:

  • Pre-transplant factors: Patient age, diagnosis, health status (e.g., diabetes, hypertension), and functional ability (measured by the New York Heart Association, or NYHA, scale).
  • Donor details: Age, donation type (e.g., after brain death, or DBD), and how lungs were transported.
  • Surgical outcomes: Operating time, cold ischemic time (how long lungs were stored outside the body), and hospital/ICU stay.
  • Post-transplant events: Infections, acute rejection, primary graft dysfunction (PGD, when the new lung fails immediately), and survival rates.

To benchmark results, they compared data to the International Thoracic Organ Transplant (TTX) Registry, a global database of lung and heart-lung transplants.

Key Findings

1. Why Patients Needed Transplants

The most common reasons for a lung transplant were:

  • Idiopathic interstitial pneumonitis (IIP): 39% of cases. IIP is a condition where the lungs become scarred for no known reason, making breathing difficult.
  • Chronic obstructive pulmonary disease (COPD): 23% of cases. COPD includes diseases like emphysema and chronic bronchitis, often caused by smoking or air pollution.
  • Pneumoconiosis: 9.2% of cases. This lung disease comes from inhaling dust (e.g., coal, silica) and is common in workers exposed to hazardous materials.
  • Rare conditions: Lymphangioleiomyomatosis (LAM), a disease where abnormal cells grow in the lungs, accounted for just 1.9% of transplants but had the best survival rates.

2. Who Received Transplants

Most recipients were men (83.2%) with a median age of 55. Notably:

  • 46.6% were over 60: Centers are increasingly evaluating older adults for transplants, which requires extra care to manage age-related health issues (e.g., weak immune systems, heart disease).
  • Common comorbidities: 14.5% had diabetes, 12.7% had hypertension, and 39.5% had a history of steroid use (which can weaken immunity).

3. Donor and Surgical Details

  • Donor age: Median 36 years. By 2018, 66.7% of donations came from people who died of brain death (DBD)—a big increase from earlier years, thanks to national efforts to promote organ donation.
  • Lung transport: Donated lungs were sent across China via planes, high-speed trains, and highways. Cold ischemic time (time lungs were stored cool outside the body) was 360 minutes for single lung transplants (SLT) and 480 minutes for bilateral (BLT). This time decreased slightly from 2015 to 2018 as transportation improved.
  • Surgical outcomes: Median ICU stay was 5 days, but 64% of patients spent more than 29 days in the hospital total—longer than average due to complications.

4. Post-Transplant Challenges

In the first 30 days after surgery, the most common issues were:

  • Infections (68.3%): Far higher than global rates (per the TTX Registry), making infections a top priority for improvement.
  • Acute rejection (17.4%): When the immune system attacks the new lung.
  • Primary graft dysfunction (PGD, 15.6%): The new lung fails immediately, often due to inflammation or injury.

For patients who survived to discharge, the standard immunosuppressive regimen (to prevent rejection) was prednisone, tacrolimus, and mycophenolate mofetil.

5. Survival Rates

Overall survival rates were:

  • 81.45% at 30 days
  • 70.11% at 1 year
  • 61.16% at 3 years

Survival varied by diagnosis:

  • LAM: 95% 1-year survival (best results, though only 20 patients).
  • Pneumoconiosis: 78.07% 1-year survival.
  • COPD: 74.40% 1-year survival.
  • IIP: 67.13% 1-year survival (lowest among common diagnoses).

Age and functional status also mattered:

  • Patients over 66 had slightly lower survival (65.59% at 1 year) but not statistically significant.
  • Patients with NYHA Class IV (severe heart failure—can’t do any physical activity without symptoms) had a 63.7% 1-year survival rate, compared to 77.8% for those with NYHA Class III.

6. Risk Factors for Death

Four factors independently increased the risk of 3-year mortality:

  1. NYHA Class IV before transplant (1.83x higher risk).
  2. ECMO use during surgery (1.51x higher risk). ECMO is a machine that takes over for the heart and lungs.
  3. Primary graft dysfunction (PGD) (2.78x higher risk).
  4. Kidney insufficiency (estimated glomerular filtration rate <60 mL·min–1·1.73 m–2, 3.13x higher risk).

What This Means for China’s Lung Transplant Program

The study highlights both progress and challenges:

Progress

  • Growing donor pool: DBD donations increased to 66.7% in 2018, up from earlier years.
  • Standardized care: Centers follow international guidelines for donor selection and surgical technique.
  • Cost access: Provinces like Jiangsu cover transplant costs through medical insurance, reducing financial barriers.

Challenges

  • Low donor utilization: Only 5.5% of donated lungs are transplanted—far lower than the global average.
  • High infection rates: Infections are the leading cause of early death, needing better prevention strategies.
  • Sicker patients: More patients with NYHA Class IV or comorbidities (e.g., diabetes) are being transplanted, requiring specialized care.

The Road Ahead

China’s lung transplant program is evolving quickly. The China Lung Transplantation Alliance now helps standardize care, share expertise, and train surgeons across the country. Future research will focus on:

  • Reducing infections and PGD.
  • Improving donor-recipient matching.
  • Long-term follow-up for older patients and those with rare diseases.

Conclusion

This study provides a vital snapshot of lung transplantation in China. While challenges remain—like low donor utilization and high infection rates—the program is making steady progress. For patients with end-stage lung disease, lung transplantation offers real hope—but continued efforts to refine care will be key to improving outcomes.

The study was published in the Chinese Medical Journal in 2019.

References

  1. Chambers DC, Cherikh WS, Goldfarb SB, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-fifth adult lung and heart-lung transplant report—2018; focus theme: multiorgan transplantation. J Heart Lung Transplant 2018;37:1169–1183. doi.org/10.1016/j.healun.07.020
  2. Gottlieb J, Smits J, Schramm R, et al. Lung transplantation in germany since the introduction of the lung allocation score: a retrospective analysis. Dtsch Arztebl Int 2017;114:179–185. doi.org/10.3238/arztebl.2017.0179
  3. Klesney-Tait J, Eberlein M, Geist L, et al. Starting a lung transplant program: a roadmap for long-term excellence. Chest 2015;147:1435–1443. doi.org/10.1378/chest.14-2241
  4. Benvenuto LJ, Anderson DR, Kim HP, et al. Geographic disparities in donor lung supply and lung transplant waitlist outcomes: a cohort study. Am J Transplant 2018;18:1471–1480. doi.org/10.1111/ajt.14630
  5. Snell GI, Paraskeva M, Westall GP. Donor selection and management. Semin Respir Crit Care Med 2013;34:361–370. doi.org/10.1055/s-0033-1348464
  6. Branch of Organ Transplantation of Chinese Medical Association, et al. Guideline on the standard of lung transplantation donors and the acquisition and transshipment in China (in Chinese). Organ Transplant 2018;9:325–333. doi.org/10.3969/j.issn.1674-7445
  7. Huang L, Chen W, Guo L, et al. Scopulariopsis/microascus isolation in lung transplant recipients: a report of three cases and a review of the literature. Mycoses 2019;62:883–892. doi.org/10.1111/myc.12952
  8. Gao F, Chen J, Wei D, et al. Lung transplantation for bronchiolitis obliterans syndrome after allogenic hematopoietic stem cell transplantation. Front Med 2018;12:224–228. doi.org/10.1007/s11684-017-0538-3
  9. Dotan Y, Vaidy A, Shapiro WB, et al. Effect of acute exacerbation of idiopathic pulmonary fibrosis on lung transplantation outcome. Chest 2018;154:818–826. doi.org/10.1016/j.chest.2018.06.027

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