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Saudi Journal of Kidney Diseases and Transplantation
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BRIEF COMMUNICATION Table of Contents   
Year : 2000  |  Volume : 11  |  Issue : 4  |  Page : 563-566
Lung Transplantation in Saudi Arabia: The Need for an Established Program

Department of Thoracic Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia

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How to cite this article:
Al-Kattan KM. Lung Transplantation in Saudi Arabia: The Need for an Established Program. Saudi J Kidney Dis Transpl 2000;11:563-6

How to cite this URL:
Al-Kattan KM. Lung Transplantation in Saudi Arabia: The Need for an Established Program. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2022 Jan 26];11:563-6. Available from: https://www.sjkdt.org/text.asp?2000/11/4/563/36644

   Introduction Top

Lung transplantation is an established therapeutic approach for patients with end­stage pulmonary disease. Since the first attempt at single lung transplantation in 1963, numerous, more successful, lung transplants have been performed all over the world. In addition to single lung transplantation, heart-lung and bilateral lung transplantations are indicated in selected patients with different pulmonary pathologies.

With the reduction achieved in mortality and morbidity associated with lung transplan­tation, more thoracic centers all over the world have well established lung transplant programs. The need to improve the quality of life of the patients as well as the failure of medical treatment for many end-stage respiratory diseases warrant the need for such a program. Despite these observations, there is no such center established in Saudi Arabia as yet. This study was conducted to evaluate the need for such a program in Saudi Arabia and to predict the difficulties and the geographical differences in our patients. We conducted a prospective evaluation of patients with end-stage pulmonary disease over a two-year period at the King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia.

   Patients and Methods Top

Over a period of two years, between October 1995 and September 1997, 43 patients with end-stage respiratory failure were evaluated. Evaluation was performed at the thoracic surgery clinic at the KKUH.

Patients were either referred from the pulmonology department in our hospital or from other hospitals in and outside Riyadh. The clinic was not officially designed as a lung transplant referral center. A lung trans­plant protocol was prepared by experienced thoracic surgeons. The protocol included donor and recipient criteria, indications for transplantation, the transplant team, the operative technique and the post-operative management. A proforma with the patient's details and the required medical data was prepared and filled for all patients who were potential candidates for lung trans­plantation.

For patients who were accepted for lung transplantation, regular follow-up visits were arranged. After two years, the data of those patients were collected and their progress was studied.

   Results Top

Forty-three patients with end-stage respi­ratory disease were evaluated. There were 28 male and 15 female patients with an average age of 43.4 ± 14 years (range 13 to 65 years). Twenty-three patients of the total (53.5%) were not accepted for transplan­tation. In five patients, the disease was stable at an acceptable disability level and lung transplantation was not indicated yet while in four others, despite the poor quality of life, the patients were satisfied with their status at the time of evaluation and hence, were not included in the potential transplant list. In the remaining 34 patients with advanced end-stage respiratory failure, the reasons for non-acceptance for transplantation were patient's refusal of the transplant despite counseling in four, post­tuberculous lung destruction with cavitation (where transplantation was not advisable in view of the presence of active disease) in six, and presence of systemic disease in four other patients. Thus, 20 patients were accepted and fully evaluated for lung transplantation. There were 12 male and eight female patients with an average age of 42 ± 9 years (range 13 to 60 years). This group represented 46.5% of all patients referred. The primary lung pathology was diffuse bronchiectasis in six, pulmonary fibrosis and pulmonary hypertension in five each, emphysema in three, and sarcoidosis in one patient. The group included three pediatric patients needing lung transplan­tation of whom two had cystic fibrosis and one had cystic lung disease.

All 20 patients were assessed initially either on out-patient or in-patient basis. They were then seen every three to six months in the clinic. During a mean follow-up period of 16 months (range 2 to 24 months), the outcome of these patients was analyzed.

During this period, three patients died due to their respiratory disease giving a mortality of 15%. One patient (5%) developed renal failure and was therefore removed from the list. One patient with bilateral emphysema underwent bilateral lung volume reduction and was omitted from the list. That resulted in a 25% reduction in the waiting list. The remaining 15 patients still live with their disabilities for want of the lung-transplan­tation facility. The cost of keeping these patients reasonably well by medical care was not calculated, but is estimated to be quite high since they often need repeated hospital admissions, home oxygen, long­term medications, in addition to the social losses (inflicted by their disabilities) on the community.

   Discussion Top

Respiratory failure secondary to end-stage pulmonary disease is a highly prevalent problem and associated with high morbidity and mortality. Accurate statistics from Saudi Arabia are lacking, but recent reports from the United States reveal that the prevalence of lung-related disease is 21.4 per 100,000 population, making it the fourth leading cause of death in the USA. [1] These patients usually have a progressive debilitating disease, which leads to decline in their quality of life and eventually their death.

Better control of recurrent infections and rejection episodes after lung transplan­tation, in addition to improved surgical and preservation techniques, have greatly improved survival after lung transplan­tation. [2] Thus, according to the 1996 registry of the International Society of Heart and Lung Transplantation, the 5-year survival after lung transplantation is around 50%. [3] Long-term results are also supportive of lung transplantation as a therapeutic option in many diseases. [4],[5] Lung transplantation not only improves survival and quality of life, but is also cost-effective. [6]

In the Kingdom of Saudi Arabia, only few lung transplantation surgeries have been performed thus far. Thus, over the last 13 years, seven single and two bilateral lung transplantation have been performed in Saudi Arabia mainly in Jeddah. In Riyadh, lung transplantation activity has begun recently and over the last two years, two bilateral and one single lung transplan­tations have been performed. The first patient was a 45-year old female with respiratory failure secondary to idiopathic pulmonary fibrosis. A single lung trans­plantation was performed via a thoracotomy incision. The patient has remained well for over two years. The second transplant was for a 38-year old male with diffuse bilateral bronchiectasis. The patient had left lower lobectomy 20 years and, right lower lobectomy 13 years prior to transplantation respectively. He was oxygen dependent and on a wheel chair for the previous one year. Prior to transplantation his condition deteriorated necessitating admission to the intensive care unit (ICU). A suitable donor became available in Kuwait. An en-block heart and lung harvesting was performed and the organs were transported to Riyadh. Via a clamshell incision, bilateral sequential lung transplantation was performed. After 24 hours of intubation the patient was transferred out of the ICU on the fifth day and was discharged after four weeks. At discharge, the patient was on room air with normal oxygen saturation and doubled pre­operative pulmonary function test. He has remained well for more than one year, when last seen, with normal life style and clear lung fields both clinically and radio­logically. The third transplant was for a 34­year old female with severe pulmonary hypertension secondary to ventricular septal defect (VSD). After an enblock heart and lung harvesting and through a clamshell incision, the VSD was repaired following which bilateral sequential lung transplan­tation was performed. The cardiac output was low at the end of surgery and the patient required prolonged ventilation. She died three weeks after surgery due to cardio-pulmonary failure.

The immunosuppression protocol in our transplant recipients includes induction with anti-thymocyte globulin for 10 days with early administration of cyclosporin A and azathioprine. Additional prednisone is given from day 10. Rejection episodes are treated with pulse methylprednisone, 500 mg given for three days. Prophylactic anti­fungal and anti-viral medications are added to the antibiotics. Thus, a limited activity in this field is being performed although established lung transplantation programs do not exist as yet in Saudi Arabia. This leaves the patients with severe lung disease with limited options. They can either continue medical treatment which is associated with progressive deterioration of their health and quality of life till death, or seek transplan­tation abroad. The latter is faced with many difficulties such as donor shortage, long waiting lists and transplants being limited to residents. Thus, patients face the prospect of prolonged hospitalization, increased cost and lack of proper follow-up.

A local center will have the advantage of being more familiar with the common regional diseases in the community such as bronchiectasis and tuberculosis. Also, our patients seem willing to accept a lower quality of life, present at an older age-group and have a high incidence of systemic diseases. Thus, counseling patients, who are basically reluctant to undergo surgical options, can be a difficult task which is best tackled by practitioners familiar with the region's culture.

Many points support establishment of a lung transplant program in Saudi Arabia. Over the last few years, a well established Saudi Center for Organ Transplantation is functioning with experienced staff. There is a general acceptance, both from religious and social view points for organ donation. The hospitals in Saudi Arabia are well equipped and staff experienced in lung transplantation are available. Also, there is good governmental support to improve health services in general, and transplan­tation in particular.

We should also consider the expected difficulties. The main problem remains donor shortage which may be related to the fact that most of the brain-death cases are secondary to road traffic accidents which generally involve thoracic injuries and/or aspiration. Thus, the donors may be unsuitable due to prolonged intubation, and the associated difficulty in maintaining the lungs in good functional status. These difficulties can be overcome as indicated by previous results. Thus, there is an urgent need to have an established lung transplant program in the region which can possibly serve all gulf countries. Efforts to educate patients and to encourage organ donation should continue.

   References Top

1.Mortality patterns, United States, 1993. Conn 1996;60:211-3.  Back to cited text no. 1    
2.Yacoub M, Al-Kattan KM, Tadjkarimi S, Eren T, Khaghani A. Medium term results of direct bronchial arterial revas-cularisation using IMA for single lung transplantation. Eur J Cardiothorac Surg 1997;11:1030-6.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Hosenpud JD, Novick RJ, Bennett LE, Keck BM, Fiol B, Dialy-OP. The registry of the International Society of Heart and Lung Transplantation: Thirteenth official report­1996. J Heart Lung Transplant 1996;15:655-­74.  Back to cited text no. 3    
4.Al Kattan K, Tadjkarimi S, Cox A, Banner N, Khagani A, Yacoub M. Evaluation of the long term results of single lung versus heart lung transplantation for emphysema. J Heart Lung Transplant 1995;14:824-31.  Back to cited text no. 4    
5.Mikhail G, Al-Kattan K, Banner N, et al. Long-term results of heart lung trans­plantation for pulmonary hypertension. Transplant Proc 1997;29:633.  Back to cited text no. 5  [PUBMED]  
6.Gartner SH, Sevick MA, Keenan RJ, Chen GJ. Cost-utility of lung transplantation: a pilot study. J Heart Lung Transplant 1997;16:1129-34.  Back to cited text no. 6  [PUBMED]  

Correspondence Address:
Khaled M Al-Kattan
Department of Thoracic Surgery, King Khalid University Hospital, P.O. Box 7805, Riyadh 11472
Saudi Arabia
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PMID: 18209346

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