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Crossing the Bridge of Eastern and Western Cultures: Lung Transplantation in Turkey

Selim M. Arcasoy, MD, MPH
Columbia University
New York, NY, USA

After the growing pains, lung transplantation is slowly becoming more common and successful in Turkey.

The first several attempts at lung transplantation in Turkey occurred in 1999 with no long-term survivors. The fifth recipient of lungs ten years later in 2009 was the first to achieve prolonged survival before succumbing to chronic allograft rejection. Between 2009 and 2014, 105 lung transplants have been performed in six centers (four of these are in Istanbul and two in Ankara). Only three of them have done more than 10 transplants while two have performed more than 30 transplants each. Interestingly, the vast majority of these transplants have occurred in non-university hospitals.

This initial six-year experience has been plagued by early postoperative and high one-year mortality rates which have translated into suboptimal long-term outcomes. However, there are interesting observations. First, silicosis and non-CF bronchiectasis seem to be the two most common indications for transplant referrals rather than interstitial pulmonary fibrosis and COPD for unclear reasons. Experienced thoracic surgeons can attest to the surgical challenges of explanting lungs from patients with silicosis and post-infectious bronchiectasis; the latter also poses other difficulties such as management of multidrug resistant infections following surgery. Second, transplant recipients during this early experience have been done on very sick who were definitely not "cherry-picked" during the pre-transplant evaluation. I had the opportunity to spend an entire day at a conference in Istanbul in 2014 to review the experience of transplant physicians in Turkey. Throughout the day, many transplant cases were presented to highlight various surgical or post-transplant medical issues, but one thing was obvious from the first slide of each presentation that outlined recipient characteristics; the candidates were very sick going into transplant. Perhaps this is one area to focus on to refine the outcomes of patients post-transplant especially during the learning and growth period of this field. There have also been tremendous successes during this early period, such as: successful use of ECMO to bridge to transplant, the use of EVLP, and cadaveric lobar lung transplant in spite of the many obstacles to success related to the lack of infrastructure and insufficient personnel in these emerging programs.

Another major challenge is donor lung availability and management in Turkey. In 2014, despite a population of 75 million, there were only 850 brain death declarations and 379 multi-organ donors; from these, only 33 lungs were used for transplantation. In order to advance the field of lung transplantation in Turkey, large efforts will have to be undertaken to improve the availability of donor lungs in parallel to the strides in patient selection and post-transplant management. An important consideration for the country is the designation of centers of excellence for lung transplantation where transplants and research are performed and training of future transplant specialists is provided during the growth phase, which is hoped to result in controlled proliferation of other successful centers.

We look forward to receiving the positive news and results of lung transplants performed in Turkey. The platform of mentorship, teaching and learning and camaraderie provided by the ISHLT can assist in the healthy development and successful growth of lung transplantation in Turkey. ■

Disclosure Statement: The authors have no conflicts interest to disclose.

References: This article was written based on information provided by Dr. Cemal Asim Kutlu, Surgical Director of Lung Transplant Program, Dept of Thoracic Surgery and Lung Transplantation, Kartal-Kosuyolu Research and Training Hospital, Istanbul, Turkey.

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