Current status and problems of lung transplantation in Japan

Abstract

Lung transplantation has been performed worldwide and recognized as an effective treatment for patients with various end-stage lung diseases. Shortage of lung donors is one of the main obstacles in most of the countries, especially in Japan. Every effort has been made to promote organ donation during the past 20 years. In 2010, Japanese transplant low was revised so that the family of the brain dead donors can make a decision for organ donation. Since then, the number of cadaveric lung donor has increased by 5-fold. However, the average waiting time is still more than 800 days resulting in considerable number of deaths on the waiting list. Lung transplantation in the use of donation after cardiac death (DCD) has now been increasingly performed in Europe, Australia and North America with promising results. However, controlled death is not permitted in Japan making it difficult to accept this strategy. Use of marginal donors is one of the strategies for organ shortage. In Japan, the rate of lung usage is now well over 60% because of careful donor management by medical consultants and aggressive use of marginal donors. Living-donor lobar lung transplantation (LDLLT) has been developed to offset the mismatch between supply and demand for those patients awaiting cadaveric lung transplantation (CLT) and it is often the most realistic option for very ill patients. Between 1998 and 2015, lung transplantation has been performed in 464 patients (55 children, 419 adults) at 9 lung transplant centers in Japan. CLT was performed in 283 patients (61%) and LDLLT was performed in 181 patients (39%). The 5-year survival was 72.3% and 71.6%, respectively. Of note, only seven children received CLT. In conclusion, lung transplantation in Japan has grown significantly with excellent results but the shortage of cadaveric lung donor remains to be an important unsolved problem. LDLLT is often the only realistic option for very ill patients especially for children.

Keywords: Lung transplantation; cadaveric lung transplantation (CLT); living-donor lobar lung transplantation (LDLLT); marginal donor.

Figure 1

Annual numbers of lung transplantation in Japan [1998–2015]. In 2010, Japanese transplant low was revised so that the family of the brain dead donors can make a decision for organ donation. Since then, the number of cadaveric lung donor has increased by 5-fold. Of note, the number of living-donor lung transplantations has not decreased.

Figure 2

Number of patients on the waiting list for lung transplantation. The number of patients on the JOTN waiting list is increasing. Currently, about 300 patients are listed, however, only about 40 patients can receive CLT annually. JOTN, Japan Organ Transplant Network; CLT, cadaveric lung transplantation.

Figure 3

Indications for lung transplantation in Japan (n=464). IP, PH, LAM and BO were four major indications followed by BE. COPD and CF were rather rare indications. IP, interstitial pneumonia; PH, pulmonary hypertension; LAM, lymphangioleiomyomatosis; BO, bronchiolitis obliterans; BE, bronchiectasis; COPD, chronic obstructive pulmonary disease; CF, cystic fibrosis.

Figure 4

The utility ratio of the lungs of brain-dead donors in Japan [1999–2014]. The utility ratio of the lungs of brain-dead donors in Japan was over 63.0% and donor/recipient ratio was 78.5%.

Figure 5

Survival after lung transplantation in Japan [1998–2015]. Lung transplantation has been performed in 464 patients at nine lung transplant centers in Japan. CLT was performed in 283 patients (61%) and LDLLT was performed in 181 patients (39%). Survival was similar between the two transplant procedures. The 5-year survival was 72.3% and 71.6%, respectively (P=0.639). CLT, cadaveric lung transplantation; LDLLT, living-donor lobar lung transplantation.

Figure 6

Survival after lung transplantation in Japan (adults vs. children). Although the number of pediatric patients was small, pediatric lung transplant recipients showed a trend toward better long-term survival than adult recipients.

Figure 7

Survival after cadaveric lung transplantation in Japan (single vs. bilateral). Among 283 patients receiving cadaveric lung transplantation, single lung transplantation (SLT) was performed in 149 patients (52.7%) and bilateral lung transplantation (BLT) was performed in 134 patients (47.3%). The survival was similar between the two procedures.