Many more lung transplants thanks to flaps of rejected lungs

By refurbishing donor lungs that have actually been rejected for transplantation with a new technique, the Erasmus Medical Centre has succeeded in giving considerably more people a new lung. The number of lung transplants has doubled over the past two years as a result of these and other innovations. This is very important for cystic fibrosis patients, for example, who are sometimes on a waiting list for a long time.

Not all people who donate organs after death have fully healthy lungs. Yet lungs that are basically rejected don’t have to be lost. With the so-called perfusion technique, lungs ‘with a scratch’ can also be successfully reused.

This is done with a perfusion machine. In such a machine, removed lungs are ventilated for four to six hours and flushed with a special fluid. Any damage to the lungs, for example due to the donor’s stay in the ICU, can be repaired. Some donors release hormones during the death process that open up blood vessels in the lungs. As a result, the lungs are filled with fluid, which makes them unusable. This can be repaired with perfusion.

Inflammations and embolisms

Medication can also be administered as antibiotics, anti-inflammatory drugs or clot dissolvers to treat embolisms. “We have thus treated organs with pneumonia. And lungs with a serious embolism, that’s a blood clot in a blood vessel in the lung. Normally these lungs were definitely rejected for transplantation,” says pulmonologist Rogier Hoek and cardio-thorac surgeon Edris Mahtab.

The technique was developed in Sweden and Canada and is now also in use in transplant centers in the Netherlands. There is a large shortage of donor lungs in our country. Some 180 people are permanently on the waiting list for a transplant. The waiting time can be up to two years and it does happen that people die while on the waiting list. A computer program assesses who gets the turn first. Lung transplants are only performed by the academic hospitals in Rotterdam, Utrecht and Groningen, a total of 109 times last year.

Donor management

To date, 49 lung transplants have been performed at Erasmus MC in 2019 and 2020. Fifteen of these lungs underwent a perfusion procedure beforehand. In combination with a few other innovations, the number of transplants could be doubled. For example, for two years doctors have been doing what they call ‘active donor management’: ‘This donor management starts as soon as it is certain that the patient will die. This means, among other things, that extra attention is paid to ventilation and fluid balance, so that the lungs are not unnecessarily damaged,” says Hoek.

The recipient of the lungs is also prepared in an innovative way. Patients whose lung function is in danger of falling below the minimum are connected to a machine that adds oxygen to the blood outside the body and thus takes over the function of the lungs. Surgeon Mahtab explains: “In this way, we can wake people up and bring them into sufficient condition to endure the operation. They used to have to be taken off the waiting list.”

Hearts?

The perfusion technique is also successfully used in Dutch hospitals to improve livers and kidneys. And a trial with hearts will soon start at Erasmus MC. “Then hopefully people waiting for a heart transplant will also be able to benefit from it,” says Hoek.

In the Netherlands, 60 percent of patients are still alive ten years after a lung transplant. This is well above the international average of 40 percent. Moreover, most patients experience a better quality of life than before lung transplantation.

Donor law

The innovations do not mean that the waiting list will disappear yet, says lung specialist Hoek: “We have to work with donor lungs that are not as good as before, because donors are getting older on average. Moreover, recipients are sicker.”

The doctors hope that the new donor law will lead to more donors. According to the new law, which has been in force since 1 July, everyone is automatically a donor, unless someone registers not wanting to.