For people living with Alpha-1 Antitrypsin Deficiency (AATD or Alpha-1), lung transplantation can become an important end-stage treatment option when lung disease has progressed beyond what other therapies can manage. This article explains the transplant process in the Australian context — from referral and eligibility through to post-operative recovery and long-term care.

What Is Lung Transplantation and Why Is It Considered for Alpha-1?

Lung transplantation is a major surgical procedure that replaces severely diseased lungs with healthy donor lungs. For people with Alpha-1 whose lungs have deteriorated to an advanced stage — typically presenting as emphysema or chronic obstructive pulmonary disease (COPD) — transplantation may be considered when no other treatments can adequately improve lung function or quality of life.

COPD is the most common reason for lung transplantation in Australia. Timely referral to a specialist transplant centre is essential, as outcomes are significantly better when patients are assessed before their condition becomes critical.

Where Are Lung Transplants Performed in Australia?

There are four adult lung transplantation centres in Australia, each of which also provides long-term post-transplant care:

• St Vincent’s Hospital, Sydney NSW
• The Alfred Hospital, Melbourne VIC
• The Prince Charles Hospital, Brisbane QLD
• Fiona Stanley Hospital, Perth WA

Each centre interprets referral guidelines according to its own clinical expertise and experience, which means there can be some variation in eligibility assessments depending on where you are assessed. If you have Alpha-1 and significant lung disease, ask your respiratory specialist whether a transplant referral is appropriate for you.

Single or Double Lung Transplant — Which Is Better for Alpha-1?

Both single and double (bilateral) lung transplants are performed in people with Alpha-1, but bilateral transplant has shown particularly strong outcomes in this population. With a single lung transplant, the remaining “native” lung — the original, diseased lung — can continue to deteriorate. Bullae (air-filled sacs) in the native lung may enlarge, or the lung may hyperinflate, which can compress and compromise the newly transplanted lung. For these reasons, bilateral transplant is often the preferred approach for people with Alpha-1-related lung disease, though each case is assessed individually.

Who Is Eligible for a Lung Transplant?

Eligibility is determined by transplant centres based on established clinical guidelines, which they apply according to their individual expertise. Conditions that may make someone unsuitable for transplantation (contraindications) include:

• Untreatable problems affecting other major organs
• A history of malignancy — generally requiring a disease-free interval of at least two years for minor cancers and five years for invasive malignancies
• Non-adherence to medical treatment
• Morbid obesity
• Active substance misuse, including alcohol, tobacco, cannabis or illicit drugs
• Age over 65, unless the person has minimal other health conditions and good physiological fitness
• Inadequate social support
• Poor rehabilitation potential

This list is not exhaustive. Your transplant team will review your individual circumstances in detail during the assessment process.

What Does the Pre-Transplant Assessment Involve?

The pre-transplant workup is thorough and covers every body system. The goal is both to assess suitability and to optimise your health before surgery. You will be seen by a multidisciplinary team that may include an immunologist, nutritionist or dietitian, dentist, dermatologist, and psychologist or psychiatrist.

• Assessments typically include:
• Full head-to-toe physical examination
• Blood tests and kidney function tests
• Liver function tests, including fibroscan for scarring or cirrhosis
• Lung function testing and CT imaging of the chest and abdomen
• Cardiac assessments — including echocardiogram, cardiac catheterisation, and coronary angiogram
• Bone density scans
• Oesophageal and swallowing assessments, including speech therapy and barium meal studies
• Gender-specific screening such as mammogram or prostate check

Maintaining a healthy body weight — neither too low nor too high — is an important part of being ready for transplant. You will attend regular appointments throughout this period.

How Long Is the Wait for a Lung Transplant?

Wait times vary considerably and cannot be predicted in advance. Factors that influence how long you wait include:

• Donor availability and compatibility of chest cavity size
• Blood and tissue type matching, and antibody considerations
• The current length of the waitlist at your centre
• Other candidates on the list who may be clinically prioritised because of greater urgency

Being on the transplant waiting list can be a stressful period. The Alpha-1 Organisation Australia can connect you with others in the Alpha-1 community who have been through this experience.

What Are the Risks of Lung Transplantation?

Lung transplantation is major surgery with significant associated risks. Before proceeding, you will be required to give informed consent, and your transplant team will explain these risks in detail. They include:

• Rejection — your immune system may recognise the donor lungs as foreign and attempt to reject them
• Infection, including serious lung infections
• Increased cancer risk, due to the immunosuppressant medications required post transplant
• Medication side effects, including diabetes and kidney damage
• Osteoporosis
• Gastrointestinal complications
• Neurological complications

These risks are managed closely by your transplant team, particularly in the first year following surgery.

What Happens After a Lung Transplant?

Recovery time varies from person to person, but most transplant recipients take three to six months to fully recover from surgery. In the early post-operative period, you may experience difficulty swallowing, speaking, or breathing deeply as you adjust to your new lungs, and you will be monitored closely for signs of acute rejection.

You will be required to live close to the hospital during the early recovery phase. If you live more than approximately 100 kilometres from your transplant centre, you may be eligible for travel or accommodation assistance through state government schemes — ask your transplant coordinator about options available in your state.

What Medications Are Required After a Lung Transplant?

Long-term immunosuppression is essential after lung transplantation to prevent rejection. Most recipients are prescribed a triple immunosuppression regimen consisting of a calcineurin inhibitor, azathioprine or mycophenolate, and prednisolone. These medications are taken for life, though dosages are typically reduced during the first year as the risk of acute rejection decreases. Infection prophylaxis is also routinely prescribed.

How Do You Stay Healthy After a Lung Transplant?

Staying well after transplant requires consistent effort and adherence to medical advice. Key recommendations include:

• Maintaining excellent food and personal hygiene
• Avoiding contact with people who are unwell (e.g. colds or influenza)
• Taking all prescribed medications reliably and as directed
• Avoiding foods and supplements known to interact with immunosuppressant medications
• Attending regular review appointments, including spirometry and bronchoscopy to monitor for rejection or infection
• Responding promptly to any decline in lung function or signs of infection
• Avoiding smoking and minimising exposure to environmental pollutants, including bushfire smoke
• Maintaining a positive outlook and engaging with peer support

Can I Speak to Someone Who Has Had a Lung Transplant?

Yes. The Alpha-1 Organisation Australia can connect you with members of the Alpha-1 community who have undergone lung transplantation. Contact A1OA on email contactus.a1oa@gmail.com.