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Lung Transplantation in Canada: Only the Beginning


links image ALIM HIRJI
University of Toronto Multi-Organ Transplant Program
Toronto, Ontario, Canada
alimhirji@gmail.com


As the annual meeting this year comes to Montréal, it is a great opportunity to take a look back at the role Canada has played in the development of the field of lung transplantation, as well as to look at the nation's ongoing contributions. As a therapeutic modality just emerging from its infancy, huge strides have been made in a short period of time to improve patient outcomes in both survival and quality of life.

Going back in time, the first human lung transplant was performed fifty years ago, on June 11, 1963, south of the border at the University of Mississippi by Dr. James Hardy. The patientwas treated post-transplant with high-dose prednisone, azathioprine, and cobalt irradiation. Unfortunately, the patient succumbed to anastomotic complications 18 days later.

Over the ensuing 20 years, several attempts at lung transplantation were made, including the first successful heart-lung transplant at Stanford University in 1981. Dr. Joel Cooper, a thoracic surgeon who settled in Toronto, Canada in 1972, began experimenting on single lung transplantation in dogs, and found that prednisone's anti-inflammatory properties were leading to impaired wound healing and subsequent bronchial anastomotic failure. In 1983, just after cyclosporine was approved for clinical use, Dr. Cooper met Tom Hall, a 58-year-old hardware executive who suffered from idiopathic pulmonary fibrosis. He candidly explained to Tom that only 44 lung transplants had been attempted worldwide and none of the patients lived more than a few weeks. Hall eagerly responded, "I'm grateful to have the opportunity to be No. 45."1 Tom was maintained after his single lung transplant on azathioprine, cyclosporine, and low-dose prednisone, and had no difficulties with anastomotic leak. He survived for 6 years after his surgery before passing from renal failure.

With such encouraging results, Dr. Cooper forged ahead, completing the first successful double lung transplant in 1986 on Ann Harrison, a Canadian with end-stage emphysema, and the first successful double lung transplant for cystic fibrosis in 1988. Soon after, he moved to Washington University, although innovation in the Toronto program did not cease.

Dr. Shaf Keshavjee joined the faculty at the University of Toronto in 1994. Under his guidance,Toronto General Hospital was the first center in North America to implement the use of the Novalung interventional lung assist device in 2006 as a means of bridging to transplant. At the forefront of his innovations, acellular normothermic Ex-Vivo Lung Perfusion has changed the global approach to the management of harvested lungs, and its use is now spreading internationally. Ever more exciting, research in Toronto in ex-vivo reparative IL-10 gene therapy is already underway.

The Toronto lung transplant program receives approximately 350 new referrals a year, and currently performs between 100-120 lung transplants per year. But although Toronto often basks in the country's spotlight, they are not the only Canadian center making leaps and bounds in the progress of lung transplantation. The University of Alberta has completed 507 lung transplants by the end of 2011 since the program started in 1986. They manage complex congenital cardiac and pulmonary cases for Western and Central Canada, and the program has broadened their care through telecommunication and multiple satellite clinic sites. Between their program in Edmonton and the BC Lung Transplant program in Vancouver, where volumes have nearly doubled in the past two years, coverage to all of Western Canada is provided. In Winnipeg, Dr. Helmut Unruh led the University of Manitoba to be the first program in Canada to perform a living lobar lung transplant, and the program provides care to Central Canada. Le Centre Hospitalier de L'Université de Montréal services Québec, providing 30-40 transplants a year.

Lung transplant activity across Canada has doubled in the past decade and by the end of 2010, 1554 lung transplants had been performed across the country, with 1387 lung transplant recipients followed across the country. In the past decade the volume of bilateral lung transplants has also increased by 85%, and 3-year survival of all-comers sits at a respectable 77.5%2.

Availability of donor lungs continues to be a challenge across Canadian provinces, and has been the impetus for driving innovation such as ex-vivo lung perfusion and Donation after Cardiac Death. Canadian institutions currently use a dichotomous Status Ranking system to allocate donor lungs, and analysis of how the UNOS-based Lung Allocation Score predicts survival in a subset of the Canadian population will be presented at the upcoming annual meeting in Montréal.

As the world comes to Canada in April, we hope that the spirit of innovation in the face of challenge, which has been a source of motivation for Canadian physicians, surgeons and scientists, will continue. International collaborative efforts will lead the way to a future with less chronic allograft dysfunction and overall better post-transplant survival. With all that has been accomplished in such a short span of fifty years, there is still yet much to do.



Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Decker, C. Cooper broke lung transplant barrier. Washington University archives of record articles. (St Louis, MO, 1995)
  2. Canadian Institute for Health Information, Canadian Organ Replacement Register Annual Report: Treatment of End-Stage Organ Failure in Canada, 2001 to 2010 (Ottawa, Ont.: CIHI, 2011).