Lung Transplantation in China Between 2015 and 2018
Lung transplantation (LT) has emerged as the only effective therapy for patients with end-stage lung diseases. In China, the increasing number of lung transplant candidates and the expanding volume of lung transplant centers necessitate well-organized programs and comprehensive registry data collection. This study aims to summarize and analyze the development of lung transplantation in China, focusing on key aspects such as transplant types, indications, donor and recipient characteristics, outcomes, and survival rates. The data were retrospectively collected from the China Lung Transplantation Registry (CLuTR) and provide valuable insights into the challenges and advancements in the field.
Lung Transplant Centers and Transplant Activity
Between January 1, 2015, and December 31, 2018, a total of 1,053 lung transplants were performed in China, as reported by 18 registered transplant centers. The number of transplants increased steadily over the years, with bilateral lung transplants (BLT) and single lung transplants (SLT) being the primary procedures. Higher-volume centers, defined as those performing more than 30 transplants per year, accounted for approximately 80% of all procedures, despite comprising only a fraction of the total qualified centers. The Wuxi Lung Transplant Center (WX) was the most active, performing over 100 transplants annually, followed by the China-Japan Friendship Hospital (CJ), the First Affiliated Hospital of Guangzhou Medical University (GZ), and the Shanghai Pulmonary Hospital (SHP).
The median age of recipients was 55.0 years, with a male predominance of 83.2%. Most recipients had a body mass index (BMI) within the normal range (18.5–24.0 kg/m²), and the distribution of blood types was relatively even across the cohort. The largest category of pre-transplant diagnoses was idiopathic interstitial pneumonitis (IIP), accounting for 39.0% of cases, followed by chronic obstructive pulmonary disease (COPD) at 23.0%. Other significant diagnoses included pneumoconiosis (9.2%), lymphangioadenomyomatosis (LAM) (1.9%), and bronchiectasis (4.8%).
Indications and Pre-Transplantation Status
The underlying diseases of recipients in China differed from those reported in Western cohorts. For instance, conditions such as alpha-1-antitrypsin deficiency, cystic fibrosis, and sarcoidosis were relatively rare in the Chinese population. Instead, IIP and COPD were the most common indications for lung transplantation. Pneumoconiosis, a condition linked to occupational exposure to dust, was also a significant contributor, reflecting the unique epidemiological profile of lung diseases in China.
The decision to perform SLT or BLT varied by indication. SLTs were more common in patients with pneumoconiosis and interstitial lung disease (ILD), while BLTs were preferred for conditions such as pulmonary hypertension, LAM, and bronchiectasis. Notably, a significant proportion of recipients were over 60 years old (46.6%), highlighting the need for careful patient selection and management in older populations.
Pre-transplant functional status was assessed using the New York Heart Association (NYHA) grading system. Most recipients were classified as NYHA III (45.6%) or IV (52.9%), indicating severe functional impairment. Comorbidities such as diabetes (14.5%) and hypertension (12.7%) were common, and many patients had a history of steroid use (39.5%) or vasoactive drug treatment (10.1%).
Donor Characteristics and Transplantation Process
Donated lungs were allocated nationwide, emphasizing the importance of efficient transportation networks, including civil aviation, high-speed trains, and highways, to ensure graft quality. The median donor age was 36.0 years, and the majority of donations were from brain-dead donors (DBD), which increased to 66.7% in 2018.
The median cold ischemic time (CIT) for SLT was 360.0 minutes, while for BLT, it was 480.0 minutes. Over the study period, there was a clear decreasing trend in CIT for BLT, reflecting improvements in organ preservation and logistics. The median total procedure time was 260.0 minutes for SLT and 390.0 minutes for BLT, with higher blood loss observed in BLT cases.
Extracorporeal membrane oxygenation (ECMO) was used in 56.4% of recipients during transplantation, and intraoperative complications were rare but included cardiac arrest (1.5%), pulmonary hematoma/laceration (0.4%), and anastomotic leaks (0.3%). Postoperatively, the median ICU stay was 5.0 days, and the median hospital stay was 36.0 days, with 64.0% of patients staying in the hospital for more than 29 days.
Post-Transplantation Outcomes and Survival
Post-transplant morbidities were primarily related to infections (68.3%), acute rejection (17.4%), renal dysfunction (16.0%), and primary graft dysfunction (PGD) (15.6%). The incidence of infections was higher in the Chinese cohort compared to international data, underscoring the need for improved infection control measures.
The overall survival rates were 81.45% at <30 days, 70.11% at 1 year, and 61.16% at 3 years. Survival rates varied by transplant type, with BLT recipients showing slightly lower survival rates than SLT recipients, although the difference was not statistically significant. In terms of disease-specific survival, patients with LAM and pneumoconiosis had superior outcomes compared to other diagnoses, with 1-year survival rates of 95.00% and 78.07%, respectively.
Age and functional status were significant predictors of survival. Older recipients (66+ years) had lower survival rates, although the difference was not statistically significant. Patients classified as NYHA IV had significantly lower survival rates compared to NYHA III patients, with 1-year survival rates of 63.70% and 77.79%, respectively.
Multivariate Cox proportional hazards regression analysis identified several independent risk factors for 3-year mortality, including NYHA IV status, ECMO use, allograft dysfunction (PGD >Grade 0), and renal insufficiency (estimated glomerular filtration rate <60 mL·min⁻¹·1.73 m⁻²). These findings highlight the importance of careful patient selection and management, particularly in high-risk populations.
Discussion
The study provides a comprehensive overview of lung transplantation in China, highlighting both the progress and challenges in the field. Despite the increasing number of transplants, the utilization rate of donated lungs remains low compared to global standards, emphasizing the need for continued efforts to improve organ donation and allocation systems.
The unique epidemiological profile of lung diseases in China, with a high prevalence of IIP, COPD, and pneumoconiosis, necessitates tailored approaches to patient selection and management. The higher incidence of post-transplant infections in the Chinese cohort underscores the importance of infection control measures and the need for further research into risk factors and prevention strategies.
The study also highlights the importance of functional status and comorbidities in predicting outcomes, with NYHA IV status and renal insufficiency being significant risk factors for mortality. These findings have important implications for patient selection and the development of targeted interventions to improve outcomes in high-risk populations.
The establishment of the China Lung Transplantation Alliance and the continued improvement of the CLuTR are critical steps toward promoting the standardization and dissemination of lung transplantation practices in China. By sharing experiences and best practices, the alliance aims to enhance the quality of care and outcomes for lung transplant recipients across the country.
In conclusion, this study provides valuable insights into the development of lung transplantation in China, highlighting both the progress made and the challenges that remain. Continued efforts to improve organ donation and allocation systems, infection control measures, and patient selection criteria are essential to further advance the field and improve outcomes for lung transplant recipients in China.
doi.org/10.1097/CM9.0000000000000543
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