Developing Strategies to Increase Donor Lung Utilisation in UK Pulmonary Transplantation

Abstract

The number of patients listed for lung transplantation exceeds the number of transplants performed annually and, over the last decade, the number of lung transplants performed in the UK has fallen. This fall has been further exacerbated by the COVID-19 pandemic of 2020/21. Access to lung transplantation is limited by the availability of suitable organs. The number of organ donors in the UK has increased over the last decade but donor demographics have changed, potentially limiting their acceptability as lung donors. Organ utilisation describes the process of accepting an organ from a potential donor, with subsequent implantation into a recipient. In UK adult lung transplant practice, the utilisation rate over the last 5 years has averaged just 19%. The aim of this work was to better understand current practice within thoracic organ utilisation, to aid the development and implementation of strategies to improve organ utilisation within pulmonary transplantation in the UK. This thesis involved five primary study areas. A retrospective review of the UK Transplant Registry (UKTR) was performed, with logistic regression analysis to identify factors predicting lung use in current practice. Organ acceptance and decision making was further explored with a qualitative interview study of clinicians’ accounts of thoracic organ utilisation. Fundamental to organ utilisation is the maintenance of safe outcomes for recipients. Primary Graft Dysfunction (PGD) is a major cause of morbidity and mortality after lung transplantation and the first national retrospective study on the incidence, grading and significance of PGD after lung transplantation was performed. Risk scores can capture elements of complex clinical decision making and several scores have previously been developed within international lung transplantation, but have not been widely adopted in UK practice. The feasibility, utility and validity of these existing scores was tested in the UK adult lung transplant population. The knowledge gained from these study areas was then used to develop the UK Lung Risk Index (UKLRI), a score devised using donor and recipient variables to predict Grade 3 PGD and 1-year survival after lung transplantation. The proportion of donors after circulatory death (DCD) in the UK is increasing. Expanding DCD lung transplantation provides a potential area for increasing lung utilisation and a retrospective study of DCD lung transplantation in the UK was performed. Finally, as the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV-2) pandemic disrupted healthcare systems globally during the course of this research, changes to heart and lung transplant practice, including organ utilisation, as a result of the pandemic, were reviewed using UKTR data analysis and a national questionnaire study.