Australian lung transplants leading the world

KEVIN Rudd’s injection of cash into the nation’s organ donation system in 2008–09 played a big part in keeping Australia at the forefront of world’s best practice in lung transplant donation, use and procedures.

Thirty-two years after the first successful lung transplant on home soil, Australian transplant teams perform around 200 adult lung transplants annually, spread across the four programs at Prince Charles Hospital in Brisbane, St Vincent’s in Sydney, the Alfred and Royal Children’s hospitals in Melbourne and the Fiona Stanley Hospital in Perth.

The average survival of lung transplant recipients in Australia is about 7 years, above the global average of 5 years, according to Dr Miranda Paraskeva, a lung transplant physician at the Alfred Hospital.

“Long term survival has continued to improve; current reported survival of bilateral lung transplant recipients at 1, 3 and 5 years [after surgery] is 90%, 74% and 68%, respectively, which exceeds international survival rates of 82%, 69% and 59%, respectively,” the authors of a Narrative Review published in the MJA wrote.

Dr Paraskeva is a co-author of the review, which dissects the transformation and current state of play in Australian lung transplant programs. Although a relative newcomer – she has been a lung transplant physician for 6 years – Dr Paraskeva benefits from working with one of the Australian pioneers of the procedure.

In 1986, Australia’s first lung transplant – it was, in fact, a heart–lung transplant – was performed in Victor Chang’s famed unit at St Vincent’s in Sydney. The first isolated lung transplant was done in 1990, also at St Vincent’s.

Head of the Alfred’s lung transplant program, Professor Greg Snell, also a co-author of the MJA review, was there at the beginning, and started the Melbourne unit.

“There’s something really interesting about being part of something in medicine where the people who started it are still working in it,” Dr Paraskeva said in an exclusive MJA podcast. “It’s definitely hard work – 24-hour a day work – but when you see people like Greg and other colleagues who have been doing it longer and are still enthusiastic and motivated, it makes it a very interesting [environment] to work in.”

Much has changed in 32 years, not least being the move to multidisciplinary care teams, improvements in surgical techniques and better pharmaceutical management of rejection. But perhaps the two biggest changes have been matters of policy.

“The big change was the increase in donor numbers thanks to the injection of cash from Kevin Rudd’s government in 2008 and 2009,” Dr Paraskeva said. “Awareness increased and so the numbers of donated organs increased exponentially. [Lung transplants] became more routine as a result.

“In the past, handfuls were performed each year, then it picked up to the mid-30s, but that injection of money made a significant difference. [At the Alfred, we] did more than 100 last year alone.”

The result has been that lung transplantation is now seen as a more reasonable and accessible treatment option.

The other change has been the acceptance of donations after circulatory death, adding to those donated after brain death.

“That added an extra pathway to donation and increased the numbers around the same time as the extra money was made available for donations,” Dr Paraskeva said. “We’re quite aggressive [at the Alfred] about pursuing donations after circulatory death, and it has significantly increased the number of patients who can access transplantation.

“It has added an extra layer of complexity.

“Unlike a donation-after-brain-death donor, who is to some degree a guaranteed donor, a donation-after-circulatory-death pathway isn’t guaranteed. There are protocols set up Australia-wide that mandate that once [the potential donor’s] treatment is withdrawn, they need to die within a certain timeframe for their organs to be utilised.

“That time is different for each organ system. Lungs are a bit more forgiving than others, but [nevertheless] there is a lot of setting up for a potential transplant that may not go ahead.

“So, [donation after circulatory death] has increased everyone’s workload without definitely increasing the output at each point, but overall it has still been a significant gain to donation with a 20% increase in transplants completed.”

These changes have meant that lung transplantation is now a reasonable treatment option for a wider range of patients, including those aged over 65 years if “there are minimal comorbidities, a paucity of relative contraindications and the ability to demonstrate reasonable physical reserve”, according to the MJA review. Children as young as 4 years are also recipients, with Australian surgeons performing three to six paediatric lung transplants a year.

Despite the improvements, lung transplantation remains a lifelong commitment by both patients and physicians, Dr Paraskeva said.

“Referral is usually to one of the four transplant centres. Lung transplantation is not a cure, it’s [a massive commitment to] lifelong follow-up,” she said.

“Some patients do choose not to do it, that it’s not for them, and that’s a valid and reasonable decision that is right for some people.

“The only way we can do it is to let them know what it involves and let them make an informed decision.

“It’s very difficult for somebody who is not involved in transplantation to know who will be responsive to transplants. We [would prefer] to see [early] referrals from doctors who think their patient might be suitable, than to say to someone that it’s too late for a lung transplant.

“Now that there are more and more being done, it’s going to be an option for more people.”

The long term care of patients after lung transplantation is par for the course for physicians like Dr Paraskeva, and it’s a big part of the satisfaction she gains from her job.

“It’s very rewarding on a patient level,” she said. “There’s the acute medicine component, but we also have the privilege of having a long-term role in our patients’ lives. We see them regularly – monthly, quarterly, depending on the patient.

“It is amazing to see people, 20 years on from their transplant, having grandkids. Part of making it a great job is seeing what happens in the long term, developing relationships with them.”

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