The history of Japanese lung transplantation: the unique pathway to establishing the program and its initial success

Japan is a unique country in terms of organ transplantation. Despite the impressive progress in transplant medicine achieved during the late 20th century in many Western countries, Japan was unable to implement a program for organ transplants from brain-dead donors due to persistent public distrust regarding the ethical understanding of "brain death as human death". In 1997, the Japanese Organ Transplant Law was enacted, and organ transplantation from brain-dead donors was finally legalized. However, this law was strongly opposed by religious leaders, philosophers, politicians, and even medical personnel who did not accept the idea that brain death is human death, so transplant physicians had to start performing transplants in the face of strong social resistance. The Japanese National Lung Transplant System was established based on the following three philosophies: (I) an institutional certification system based on strict standards; (II) a rigorous central monitoring system for transplant results; and (III) a third-party review system to determine eligibility for patient registration. The purpose of these policies was to avoid ethical issues at lung transplant institutes, and to achieve high-quality transplant results. The actual progress of Japanese lung transplantation has been quite unusual compared to other countries. The number of brain-dead organ donations was extremely limited at first, so more than 60% of lung transplants were performed as living-donor transplants during the first 9 years [1998-2006]. The number of brain-dead donations subsequently increased, particularly after the revision of the Organ Transplant Law in 2010 such that the majority of lung transplants are now performed as brain-dead transplantations. Regarding the results of lung transplants, the most recent national registry report indicated that a total of 668 lung transplants including 447 from brain-dead donors and 221 from living donors, had been performed as of 2018. The 5- and 10-year survival rates for brain-dead donor lung transplantation were 71.9% and 57.8%, respectively, with no significant difference between the living-donor and brain-dead-donor groups. These results are comparable with the outcome of preceding programs in the US and European countries.