What is lung transplant

A lung transplant is a surgical procedure that involves removing a person’s diseased lung and replaces it with a healthy one from a donor. The healthy lung usually comes from a donor who has died. Some people get one lung during a transplant. Other people get two (double lung transplant). A lung transplant can save the life of the person who receives the new healthy lung. In most cases, the new lung or lungs are donated by a person who is under age 65 and brain-dead, but is still on life-support. The donor lungs must be disease-free and matched as closely as possible to your tissue type. This reduces the chance that your body will reject the transplanted lung(s). Lungs can also be given by living donors. Two or more people are needed. Each person donates a segment (lobe) of their lung. This forms an entire lung for the person who is receiving it.

The world’s first successful lung transplant, a combined heart and double lung transplant, was performed at Stanford University Medical Center in 1981. Since that time there have been over 30,000 lung transplants performed throughout the world.

Lung transplants are used for people who are likely to die from lung disease within 1 to 2 years. Their conditions are so severe that other treatments, such as medicines or breathing devices, no longer work. Lung transplants most often are used to treat people who have severe

• Chronic obstructive pulmonary disease (COPD)
• Cystic fibrosis
• Idiopathic pulmonary fibrosis
• Alpha-1 antitrypsin deficiency
• Pulmonary hypertension

Complications of lung transplantation include rejection of the transplanted lung and infection.

Lung transplants are used to improve the quality of life and extend the lifespan for people who have severe or advanced chronic lung conditions. In rare instances, a lung transplant may be performed at the same time as a heart transplant in patients who have severe heart and lung disease.

You may be eligible for lung transplant surgery if you have severe lung disease that does not respond to other treatments. If you are otherwise healthy enough for surgery, you will be placed on the National Organ Procurement and Transplantation Network’s waiting list. This network handles the nation’s organ-sharing process. If a match is found, you will need to have your lung transplant surgery right away.

Lung transplant surgery will be performed in a hospital. You will have general anesthesia and will not be awake for the surgery. Tubes will help you breathe, give you medicine, and help with other bodily functions. A surgeon will open your chest, cut the main airway and blood vessels, and remove your diseased lung. The surgeon will connect the healthy donor lung, reconnect the blood vessels, and close your chest.

After the surgery, you will recover in the hospital’s intensive care unit (ICU) before moving to a hospital room for one to three weeks. Your doctor may recommend pulmonary rehabilitation after your lung transplant surgery to help you regain and improve your breathing. Pulmonary rehabilitation may include exercise training, education, and counseling. Pulmonary function tests will help doctors monitor your breathing and recovery. After leaving the hospital, you will visit your doctor often to check for infection or rejection of your new lung, to test your lung function, and to make sure that you are recovering well.

It usually takes at least three to six months to fully recover from transplant surgery. For the first six weeks after surgery, avoid pushing, pulling or lifting anything heavy. You’ll be encouraged to take part in a rehabilitation programme involving exercises to build up your strength.

You should be able to drive again four to six weeks after your transplant, once your chest wound has healed and you feel well enough.

Depending on the type of job you do, you’ll be able to return to work around three months after surgery.

The first year after lung transplant surgery is when you are most at risk for possibly life-threatening complications such as rejection and infection. To help prevent rejection, you will need to take medicines for the rest of your life that suppress your immune system and help prevent your body from rejecting your new lungs. These important medicines weaken your immune system and increase your chance for infections, and over time they can increase your risk for cancer, diabetes, osteoporosis, and kidney damage. Practicing good hygiene, obtaining routine vaccines, and adopting healthy lifestyle choices such as heart-healthy eating and not smoking are very important. Getting emotional support and following your doctor’s advice will help you recover and stay as healthy as possible.

A lung transplant can substantially improve your quality of life. The first year after the transplant — when surgical complications, rejection and infection pose the greatest threats — is the most critical period.

Although some people have lived 10 years or more after a lung transplant, only about half the people who undergo the procedure are still alive after five years.

How long does a lung transplant last?

For single lung transplants the operation takes 4 to 8 hours. And for double lung transplant the surgery takes 6 to 12 hours.

What is the cost of a lung transplant?

There were 3,128 Medicare lung transplant recipients identified through linkage of transplant registry and Medicare administrative claims from May 4, 2005 to December 31, 2011 ¹. Unadjusted transplant cost was lower at high-volume centers (mean $131,352; median $90,177; interquartile range $79,165–$137,915) than at intermediate-volume (mean $138,792; median $93,024; interquartile range $82,700–$154,857) or low-volume (mean $143,609; median $95,234; interquartile range $83,052–$152,149) centers ¹. After adjusting for recipient health risk, low-volume centers had an 11.66% greater transplant admission cost, a 41% greater risk for in-hospital mortality  and a 14% greater risk for early hospital readmission compared with high-volume centers ¹. There was no significant difference in transplant cost, in-hospital mortality, or early hospital readmission between intermediate- and high-volume centers ¹.

Types of lung transplant

There are three main types of lung transplant:

1. Single lung transplant – where a single damaged lung is removed from the recipient and replaced with a lung from the donor; this is often used to treat pulmonary fibrosis, but it isn’t suitable for people with cystic fibrosis because infection will spread from the remaining lung to the donated lung
2. Double lung transplant – where both lungs are removed and replaced with two donated lungs; this is usually the main treatment option for people with cystic fibrosis or COPD
3. Heart and lung transplant – where the heart and both lungs are removed and replaced with a donated heart and lungs; this is often recommended for people with severe pulmonary hypertension

The demand for lung transplants is far greater than the available supply of donated lungs. Therefore, a transplant will only be carried out if it’s thought there’s a relatively good chance of it being successful.

For example, a lung transplant wouldn’t be recommended for someone with lung cancer because the cancer could reoccur in the donated lungs.

You also won’t be considered for a lung transplant if you smoke.

Lung transplant criteria

Generally patients with end-stage lung disease who meet the following criteria are considered for lung transplantation:

• Untreatable end-stage lung disease due to any cause
• Absence of other significant medical diseases
• Substantial limitation of daily activities
• Limited life expectancy
• Satisfactory psychosocial profile and emotional support system

In most cases, a lung transplant is done only after all other treatments for lung failure are unsuccessful. Lung transplants may be recommended for people under age 65 who have severe lung disease. Some examples of diseases that may require a lung transplant are:

• Cystic fibrosis
• Damage to the arteries of the lung because of a defect in the heart at birth (congenital defect)
• Destruction of the large airways and lung (bronchiectasis)
• Emphysema or chronic obstructive pulmonary disease (COPD)
• Lung conditions in which the lung tissues become swollen and scarred (interstitial lung disease) e.g., pulmonary fibrosis
• High blood pressure in the arteries of the lungs (pulmonary hypertension)
• Sarcoidosis
• Alpha-1 antitrypsin deficiency
• Lymphangioleiomyomatosis

Lung damage can often be treated with medication or with special breathing devices. But when these measures no longer help or your lung function becomes life-threatening, your doctor might suggest a single-lung transplant or a double-lung transplant.

Some people with coronary artery disease may need a procedure to restore blood flow to a blocked or narrowed artery in the heart, in addition to a lung transplant. In some cases, people with serious heart and lung conditions may need a heart-lung transplant.

Lung transplant may not be done for people who:

• Are too sick or badly nourished to go through the procedure
• Continue to smoke or abuse alcohol or other drugs
• Have active hepatitis B, hepatitis C, or HIV
• Have had cancer within the past 2 years
• Have lung disease that will likely affect the new lung
• Have severe disease of other organs
• Cannot reliably take their medicines
• Are unable to keep up with the hospital and health care visits and tests that are needed.

Absolute contraindications to lung transplantation include:

• Serious disease of the kidney and liver
• Active infection outside the lungs
• Smoking or substance abuse
• Progressive neuromuscular disease
• Active malignancy within the past 2 years (with the exception of basal and squamous cell carcinoma of the skin).

Factors that may affect your eligibility for a lung transplant

A lung transplant isn’t the right treatment for everyone. Certain factors may mean you’re not a good candidate for a lung transplant. While each case is considered individually by a transplant center, a lung transplant may not be appropriate if you:

• Have an active infection
• Have a recent personal medical history of cancer
• Have serious diseases such as kidney, liver or heart diseases
• Are unwilling or unable to make lifestyle changes necessary to keep your donor lung healthy, such as not drinking alcohol or not smoking
• Do not have a supportive network of family and friends

Lung transplant procedure

Preparations for a lung transplant often begin long before the surgery to place a transplanted lung. You may begin preparing for a lung transplant weeks, months or years before you receive a donor lung, depending upon the waiting time for a transplant.

Taking the first steps

If your doctor recommends that you consider a lung transplant, you’ll likely be referred to a transplant center for evaluation. You’re also free to select a transplant center on your own. When evaluating a lung transplant center:

• Check with your health insurance provider to see which transplant centers are covered under your insurance plan.
• Consider the number of lung transplants a center performs each year and transplant recipient survival rates by reviewing a database on the web maintained by the Scientific Registry of Transplant Recipients (https://www.srtr.org/).
• Consider additional services that may be provided by a transplant center, such as support groups, assistance with travel arrangements, help finding local housing for your recovery period or information about organizations that can help with these concerns.

Once you decide where you would like to have your lung transplant, you’ll need to have an evaluation to see if you’re eligible for a lung transplant. During an evaluation, your doctors and transplant team may review your medical history, conduct a physical examination, order several tests, and evaluate your mental and emotional health.

Your transplant team will also discuss with you the benefits and risks of a transplant and what to expect before, during and after a transplant.

Waiting for a donor organ

If the transplant team determines that you’re a candidate for a lung transplant, the transplant center will register you and place your name on a waiting list. The number of people needing lung transplants far exceeds the number of donated lungs available. Unfortunately, some people die while waiting for a transplant.

While you’re on the waiting list, your medical team will closely monitor your condition and alter your treatment as needed. Your doctor may recommend healthy lifestyle changes, such as eating a healthy diet, getting regular exercise and avoiding tobacco.

Your doctors may recommend that you participate in a pulmonary rehabilitation program while you wait for a donor lung. Pulmonary rehabilitation can help you improve your health and ability to function in daily life before and after your transplant.

When a donor organ becomes available, the donor-recipient matching system administered by the United Network for Organ Sharing (https://unos.org/) finds an appropriate match based on specific criteria, including:

• Blood type
• Size of organ compared with chest cavity
• Geographic distance between donor organ and transplant recipient
• Severity of the recipient’s lung disease
• Recipient’s overall health
• Likelihood that the transplant will be successful

Immediately before your transplant surgery

It may take months or even years before a suitable donor becomes available, but you must be prepared to act quickly when one does. Make sure the transplant team knows how to reach you at all times.

Keep your packed hospital bag handy — including an extra 24-hour supply of your medications — and arrange transportation to the transplant center in advance. You may be expected to arrive at the hospital within just a few hours.

Once you arrive at the hospital, you will undergo tests to make sure the lung is a good match and that you are healthy enough to have the surgery. The donor lung also must be healthy, or it will be declined by the transplant team. The transplant will be canceled if it doesn’t appear that the surgery will be a success.

Before the lung transplant procedure

You will have the following tests to determine if you are a good candidate for the operation:

• Blood tests or skin tests to check for infections
• Blood typing
• Tests to evaluate your heart, such as electrocardiogram (EKG), echocardiogram, or cardiac catheterization
• Tests to evaluate your lungs
• Tests to look for early cancer (Pap smear, mammogram, colonoscopy)
• Tissue typing, to help make sure your body will not reject the donated lung
• Psychological assessment
• Referral to other practitioners such as physiotherapy, occupational health and safety and a dietician.

During the assessment, you’ll be able to meet members of the transplant team and ask questions. Your transplant team will include:

• surgeons
• anesthetists
• intensive care specialists
• lung specialists
• specialists in infection
• a transplant nurse
• physiotherapists
• psychologists
• social workers
• a transplant co-ordinator

The transplant co-ordinator will be your main point of contact. They’ll talk to you and your family about what happens during a lung transplant and the risks involved.

After the assessment is complete, a decision will be made as to whether a lung transplant is suitable for you and whether it’s the best option.

It may be decided that:

• you should go on the active waiting list – which means you could be called for a transplant at any time
• a transplant is suitable for you, but your condition isn’t severe enough – you’ll be reviewed regularly and if your condition worsens, you’ll be put on the active waiting list
• you need more investigations or treatment before a decision can be made
• a transplant isn’t suitable for you – the assessment team will explain why and offer alternatives, such as medication or other surgery
• you need a second opinion from a different transplant center

Good candidates for lung transplant are put on a regional waiting list. Your place on the waiting list is based on a number of factors, including:

• What type of lung problems you have
• The severity of your lung disease
• The likelihood that a transplant will be successful

For most adults, the amount of time you spend on a waiting list usually does not determine how soon you get a lung. Waiting time is often at least 2 to 3 years.

While you are waiting for a new lung:

• Follow any diet your lung transplant team recommends. Stop drinking alcohol, do not smoke, and keep your weight in the recommended range.
• Take all medicines as they were prescribed. Report changes in your medicines and medical problems that are new or get worse to the transplant team.
• Follow any exercise program that you were taught during pulmonary rehabilitation.
• Keep any appointments that you have made with your regular health care provider and transplant team.
• Let the transplant team know how to contact you right away if a lung becomes available. Make sure that you can be contacted quickly and easily.
• Be prepared in advance to go to the hospital.

Before your lung transplant procedure, always tell your doctor:

• What drugs, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription
• If you have been drinking a lot of alcohol (more than one or two drinks a day)

Do not eat or drink anything when you are told to come to the hospital for your lung transplant. Take only the drugs that you have been told to take with a small sip of water.

Why a lung transplant might be unsuitable

The supply of donor lungs is limited, which means there are more people who would benefit from a lung transplant than there are donor lungs.

Therefore, people who are unlikely to have a successful transplant aren’t usually considered suitable for transplant.

You may also be considered unsuitable if:

• you haven’t complied with previous advice or been reliable – for example, if you haven’t given up smoking, you have a poor history of taking prescribed medication or you’ve missed hospital appointments
• your other organs, such as your liver, heart or kidneys, don’t function well and, therefore, may fail after the stresses of the transplant operation
• your lung disease is too advanced, so it’s thought you would be too weak to survive surgery
• you have a recent history of cancer – there’s a chance that the cancer could spread into the donated lungs; exceptions can be made for some types of skin cancer as these are unlikely to spread
• you have an infection that would make the transplant too dangerous
• you have psychological and social problems that may affect whether you take post-transplant treatments; such as being addicted to drugs or having a serious mental health condition
• you’re significantly underweight with a body mass index (BMI) of less than 16, or very overweight (obese) with a BMI of 30 or above

Age also plays a part, because of the effect it has on likely survival rates. There are no set rules and exceptions can always be made, but as a general rule:

• people over 50 years of age wouldn’t be considered suitable for a heart-lung transplant
• people over 65 years of age wouldn’t be considered suitable for a single or double lung transplant (although those over 65 and otherwise healthy may be considered for a single lung transplant)

Lung transplant surgery

During lung transplant surgery, you are asleep and pain-free (under general anesthesia). A surgical cut is made in the chest. Lung transplant surgery is often done with the use of a heart-lung machine. This device does the work of your heart and lungs while your heart and lungs are stopped for the surgery.

• For single lung transplants, the cut is made on the side of your chest where the lung will be transplanted. The operation takes 4 to 8 hours. In most cases, the lung with the worst function is removed.
• For double lung transplants, the cut is made below the breast and reaches to both sides of the chest. Surgery takes 6 to 12 hours.

After the cut is made, the major steps during lung transplant surgery include:

• You are placed on the heart-lung machine.
• One or both of your lungs are removed. For people who are having a double lung transplant, most or all of the steps from the first side are completed before the second side is done.
• The main blood vessels and airway of the new lung are sewn to your blood vessels and airway. The donor lobe or lung is stitched (sutured) into place. Chest tubes are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.
• You are taken off the heart-lung machine once the lungs are sewn in and working.

Sometimes, heart and lung transplants are done at the same time (heart-lung transplant) if the heart is also diseased.

Lung transplant recovery

Immediately after the lung transplant surgery, you’ll spend several days in the hospital’s intensive care unit (ICU). A mechanical ventilator will help you breathe for a few days, and tubes in your chest will drain fluids from around your lungs and heart.

A tube in a vein will deliver strong medications to control pain and to prevent rejection of your new lung. As your condition improves, you’ll no longer need the mechanical ventilator, and you’ll be moved out of the ICU. Recovery after a lung transplant often involves a 7 to 21 days hospital stay. The amount of time you’ll spend in the ICU and in the hospital can vary. Most centers that perform lung transplants have standard ways of treating and managing lung transplant patients.

Lung transplant recovery period is about 6 months. Often, your transplant team will ask you to stay close to the hospital for the first 3 months. You will need to have regular check-ups with blood tests and x-rays for many years.

After you leave the hospital, you’ll require about three months of frequent monitoring by the lung transplant team to prevent, detect and treat complications and to assess your lung function. During this time, you’ll generally need to stay close to the transplant center. Afterward, the follow-up visits are usually less frequent, and it’s easier to travel back and forth for follow-up visits.

Your follow-up visits may involve laboratory tests, chest X-rays, an electrocardiogram (ECG), lung function tests, a lung biopsy and checkups with a specialist.

In a lung biopsy, doctors remove very small lung tissue samples to test for signs of rejection and infection. This test may be conducted during a bronchoscopy, in which a doctor inserts a small, flexible tube through the mouth or nose into the lungs. A light and small camera attached to the bronchoscope allows the doctor to look inside the lungs’ airways. The doctor may also use special tools to remove small samples of lung tissue to test in a lab.

Your transplant team will monitor you closely and help you manage immunosuppressant medications’ side effects. Your transplant team may also monitor and treat infections. Your doctor might prescribe antibiotic, antiviral or antifungal medications to help prevent infections. Your transplant team may also instruct you about ways you can help prevent infections at home.

You’ll also be monitored for any signs or symptoms of rejection, such as shortness of breath, fever, coughing or chest congestion. It’s important to let your transplant team know if you notice any signs or symptoms of rejection.

You’ll generally need to make several long-term adjustments after your lung transplant, including:

• Taking immunosuppressants. You’ll need to take immunosuppressant medications for life to suppress your immune system and prevent rejection of the donor lung or lungs.
• Managing medications, therapies and a lifelong care plan. Your doctor may give you instructions to follow after your transplant. It’s important to take all your medications as your doctor instructs, check your lung function as directed by your doctor, attend follow-up appointments and follow a lifelong care plan. It’s a good idea to set up a daily routine for taking your medications so that you won’t forget. Keep a list of all your medications with you at all times in case you need emergency medical attention, and tell all your doctors what you take each time you’re prescribed a new medicine.
• Living a healthy lifestyle. Living a healthy lifestyle is key to sustaining your new lung. Your doctor may advise you to not use tobacco products and to limit alcohol use. Following a nutritious diet also can help you stay healthy. Exercise is an extremely important part of rehabilitation after your lung transplant and will begin within days of your surgery. Your health care team will likely work with you to design an exercise program that’s right for you. Your doctor may recommend pulmonary rehabilitation — a program of exercise and education that may help improve your breathing and daily functioning — after your transplant.
• Emotional support. Your new medical therapies and the stress of having a lung transplant may make you feel overwhelmed. Many people who have had a lung transplant feel this way. Talk to your doctor if you’re feeling stressed or overwhelmed. Transplant centers often have support groups and other resources to help you manage your condition.

Lung transplant medications

You’ll need to take immunosuppressant medications after your lung transplant for life to prevent rejection. These medications may cause serious side effects, and they may cause you to be more susceptible to infections. Your treatment team will explain your medications and potential side effects. Your doctors will help you manage your immunosuppressant medications, based on your side effects and any signs of rejection.

There are usually two stages in immunosuppressant therapy:

1. Induction therapy – where you’re given a combination of high dose immunosuppressants immediately after the transplant to weaken your immune system; you may also be given antibiotics and antivirals to prevent infection
2. Maintenance therapy – where you’re given a combination of immunosuppressants at a lower dose to “maintain” your weakened immune system

You’ll need to have maintenance therapy for the rest of your life.

Most transplant centres use the following combination of immunosuppressants:

• tacrolimus
• mycophenolate mofetil
• corticosteroids

The downside of taking immunosuppressants is that they can cause a wide range of side effects, including:

• mood changes, such as depression or anxiety
• insomnia
• diarrhea
• swollen gums
• bruising or bleeding more easily
• convulsions
• dizziness
• headache
• acne
• extra hair growth (hirsutism)
• weight gain

Your doctor will try to find an immunosuppressant dose that’s high enough to “dampen” the immune system, but low enough that you experience few side effects. This may take several months to achieve.

Even if your side effects become troublesome, you should never suddenly stop taking your medication because your lungs could be rejected.

Long-term use of immunosuppressants also increases your risk of developing other health conditions such as kidney disease (read more about the side effects of anti-rejection drugs use in the risks section below).

In the past, people with lung transplants usually have taken corticosteroids (prednisone, others) and other immunosuppressant medications for life to prevent rejection. However, corticosteroids may cause weight gain, high blood pressure, osteoporosis, and other side effects and complications.

You may be able to reduce or stop taking corticosteroids at some time after your lung transplant, which may lessen your side effects and complications. You’ll still need to take other immunosuppressant medications.

Other immunosuppressant medication options that may be used for people with lung transplants include basiliximab (Simulect), mycophenolate mofetil (CellCept) and azathioprine (Imuran).

Doctors may sometimes prescribe medications called sirolimus (Rapamune) or everolimus (Afinitor) about 3 months after a lung transplant. These drugs may be considered for people who can’t tolerate mycophenolate mofetil and azathioprine. These medications will only be used after there has been adequate healing of the airway after transplant.

Doctors may also prescribe sirolimus or everolimus to people experiencing kidney problems due to calcineurin inhibitors — another immunosuppressant. In some cases, people with kidney problems after transplant may be able to reduce or stop taking calcineurin inhibitors if they are taking sirolimus or everolimus, and their kidney problems may improve.

Researchers continue to study the potential use of other immunosuppressant medications for people with lung transplants.

Preventing infection

Having a weakened immune system is known as being immunocompromised. If you’re immunocompromised, you’ll need to take extra precautions against infection. You should:

• practise good personal hygiene – take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly
• avoid contact with people with infections that could seriously affect you – such as chickenpox or influenza (flu)
• wash your hands regularly with soap and hot water – particularly after going to the toilet and before preparing food and eating meals
• take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it, and then cover it with a sterile dressing
• keep up to date with regular immunizations – your transplant center will supply you with all the relevant details

You should also look out for any initial signs that may indicate you have an infection. A minor infection could quickly turn into a major one.

Tell your doctor or transplant center immediately if you have symptoms of an infection, such as:

• a fever (high temperature) of 100.4 °F (38 °C) or above
• headache
• aching muscles

Lung transplant risks

A lung transplant is a complex operation and the risk of complications is high. Complications associated with a lung transplant can sometimes be fatal. Major risks include rejection and infection.

Risks of lung transplant include:

• Blood clots (deep venous thrombosis).
• Diabetes, bone thinning, or high cholesterol levels from the medicines given after a transplant.
• Increased risk for infections due to anti-rejection (immunosuppression) medicines.
• Damage to your kidneys, liver, or other organs from anti-rejection medicines.
• Future risk of certain cancers.
• Problems at the place where the new blood vessels and airways were attached.
• Rejection of the new lung, which may happen right away, within the first 4 to 6 weeks, or over time.
• The new lung may not work at all.

Common complications include:

• Infection
• Rejection of the donor lung
• Pneumonia
• Excessive bleeding
• Anesthesia-related problems
• Cancer related to taking immunosuppressant medications
• Death

Reimplantation response

Reimplantation response is a common complication affecting almost all people with a lung transplant. The effects of surgery and the interruption to the blood supply cause the lungs to fill with fluid.

Symptoms include:

• coughing up blood
• shortness of breath
• difficulties breathing while lying down

The symptoms are usually at their worst five days after the transplant. These problems will gradually improve, and most people are free of symptoms by 10 days after their transplant.

Lung transplant rejection

Your immune system defends your body against foreign substances. Even with the best possible match between you and the donor, your immune system will try to attack and reject your new lung or lungs. The risk of rejection is highest soon after the lung transplant and is reduced over time.

Your drug regimen after transplant will include medications to suppress your immune system (immunosuppressant medications) in an effort to prevent organ rejection. You’ll likely take these anti-rejection drugs for the rest of your life.

Graft rejection is classified into three types:

1. Hyperacute rejection, marked by activation of complement and coagulation cascades in response to binding of preformed host antibodies to endothelial cells of the graft. This is more likely in patients with previous exposure to foreign peptides such as blood transfusion recipients, pregnant women, or prior transplant recipients.
2. Acute rejection which histologically defined as a mononuclear leukocyte infiltrate of small airways and blood vessels. If left untreated acute rejection may progress to chronic allograft rejection.
3. Chronic rejection.

Most people experience rejection, usually during the first three months after the transplant. Shortness of breath, fatigue (extreme tiredness), and a dry cough are all symptoms of rejection, although mild cases may not always cause symptoms.

Acute rejection usually responds well to treatment with steroid medication.

Walking is recommended to restore strength and prevent lung complications. More strenuous activity can resume when one is comfortable.

Side effects of anti-rejection drugs

Taking immunosuppressant medications is necessary following any type of transplant, although they do increase your risk of developing other health conditions.

Anti-rejection drugs may cause noticeable side effects, including:

• Weight gain
• Tremors
• A rounder face
• Acne
• Facial hair
• Stomach problems

Some anti-rejection medications can also increase your risk of developing new conditions or aggravating existing conditions, such as:

• Diabetes
• Kidney damage
• Osteoporosis
• Cancer
• High blood pressure (hypertension)

Kidney disease

Kidney disease is a common long-term complication. It’s estimated that one in four people who receive a lung transplant will develop some degree of kidney disease a year after the transplant.

About 1 in 14 people will experience kidney failure within a year of their transplant, rising to 1 in 10 after five years.

Diabetes

Diabetes, specifically type 2 diabetes, develops in around one in four people a year after the transplant.

Diabetes is treated using a combination of:

• lifestyle changes, such as taking regular exercise
• medication, such as metformin or injections of insulin

High blood pressure

High blood pressure develops in around half of all people a year after a lung transplant and in eight out of 10 people after five years.

High blood pressure can develop due to a side effect of immunosuppressants or as a complication of kidney disease.

Like diabetes, high blood pressure is treated using a combination of lifestyle changes and medication.

Osteoporosis

Osteoporosis (weakening of the bones) usually arises as a side-effect of immunosuppressant use.

Treatment options for osteoporosis include vitamin D supplements (which help strengthen bones) and a type of medication known as bisphosphonates, which help maintain bone density.

Cancers

People who have received a lung transplant have an increased risk of developing cancer at a later date. This would usually be one of the following:

• skin cancer
• lung cancer
• liver cancer
• kidney cancer
• non-Hodgkin lymphoma – which is a cancer of the lymphatic system

Because of this increased risk, regular check-ups for these sorts of cancers may be recommended.

Risk of infection

The anti-rejection drugs suppress your immune system, making your body more vulnerable to infections, particularly in your lungs.

The risk of infection for people who’ve received a lung transplant is higher than average for a number of reasons, including:

• immunosuppressants weaken the immune system, which means an infection is more likely to take hold and a minor infection is more likely to progress to a major infection
• people often have an impaired cough reflex after a transplant, which means they’re unable to clear mucus from their lungs, providing the perfect environment for infection
• surgery can damage the lymphatic system, which usually protects against infection
• people may be resistant to one or more antibiotics as a consequence of their condition, particularly those with cystic fibrosis

Common infections after a transplant include:

• bacterial or viral pneumonia
• cytomegalovirus (CMV)
• aspergillosis – a type of fungal infection caused by spores

To help prevent infections, your doctor may recommend that you:

• Wash your hands regularly
• Brush your teeth and gums regularly
• Protect your skin from scratches and sores
• Avoid crowds and people who are ill
• Receive appropriate vaccinations

Bronchiolitis obliterans syndrome

Bronchiolitis obliterans syndrome (BOS) is another form of rejection that typically occurs in the first year after the transplant, but could occur up to a decade later.

In bronchiolitis obliterans syndrome, your immune system causes the airways inside the lungs to become inflamed, which blocks the flow of oxygen through the lungs.

Symptoms include:

• shortness of breath
• dry cough
• wheezing

Bronchiolitis obliterans syndrome may be treated with additional immunosuppressant medications.

Post-transplantation lymphoproliferative disorder

After having a lung transplant, your risk of developing a lymphoma (usually a non-Hodgkin lymphoma) is increased. This is known as post-transplantation lymphoproliferative disorder (PTLD).

Post-transplantation lymphoproliferative disorder occurs when a viral infection (usually the Epstein-Barr virus) develops as a result of the immunosuppressants that are used to stop your body rejecting the new organ.

Post-transplantation lymphoproliferative disorder affects around one in 20 people who have a lung transplant. Most cases occur within the first year of the transplant. It can usually be treated by reducing or withdrawing immunosuppressant therapy.

Lung transplant success rate

Regardless of the form of transplant (single lung, double lung or heart and double lung) the majority of patients (approximately 93%) will live at least a year or more following their transplant with 70% living 5 or more years. Quality of life as measured by ability to exercise, attend educational courses, work or manage a household is usually excellent. Most patients return to a relatively normal life after a lung transplant.

Lung transplant survival rate

A lung transplant is a major procedure that is performed for people with life-threatening lung disease or damage.

• About four out of five patients are still alive 1 year after the lung transplant.
• About two out of five lung transplant recipients are alive at 5 years.
• The highest risk of death is during the first year, mainly from problems such as rejection.

Fighting rejection is an ongoing process. Your body’s immune system considers the transplanted lung as an invader and may attack it.

To prevent rejection, lung transplant patients must take anti-rejection (immunosuppression) drugs. These drugs suppress your body’s immune response and reduce the chance of rejection. As a result, however, these drugs also reduce your body’s natural ability to fight off infections.

By 5 years after a lung transplant, at least one in five people develop cancers or have problems with the heart. For most people, the quality of life is improved after a lung transplant. They have better exercise endurance and are able to do more on a daily basis.

Lung transplant life expectancy

The British Transplantation Society estimates that around nine out of 10 people survive a lung transplant, with most of these surviving for at least a year after having the operation.

About five out of 10 people will survive for at least five years after having a lung transplant, with many people living for at least 10 years. There have also been reports of some people living for 20 years or more after a lung transplant.

Although complications can occur at any time, a serious complication is most likely to occur in the first year after the transplant.

Life after lung transplant

Diet and nutrition

After your lung transplant, you may need to adjust your diet to stay healthy. Maintaining a healthy weight through diet and exercise can help you avoid complications such as high blood pressure, heart disease and diabetes.

Your transplant team includes a nutrition specialist (dietitian) who can discuss your nutrition and diet needs and answer any questions you may have after your transplant.

Your dietitian will provide you with several healthy food options and ideas to use in your eating plan. Your dietitian’s recommendations may include:

• Eating plenty of fruits and vegetables each day
• Eating whole-grain breads, cereals and other products
• Drinking low-fat or fat-free milk or eating other low-fat or fat-free dairy products, to help maintain enough calcium in your body
• Eating lean meats, such as fish or poultry
• Maintaining a low-salt diet
• Avoiding unhealthy fats, such as saturated fats or trans fats
• Avoiding grapefruit and grapefruit juice due to their effects on a group of immunosuppressive medications (calcineurin inhibitors)
• Avoiding excessive alcohol
• Staying hydrated by drinking adequate water and other fluids each day
• Following food safety guidelines to reduce the risk of infection.

Exercise after lung transplant

Your treatment team may recommend exercise after lung transplant to improve health.

After your lung transplant, your doctor and treatment team may recommend that you make exercise and physical activity a regular part of your life to continue to improve your overall physical and mental health.

Exercising regularly helps you control your blood pressure, control stress, maintain a healthy weight, strengthen your bones and increase your physical function. As you become more fit, your body is able to use oxygen more effectively.

Your treatment team will create an exercise program to meet your needs. You’ll likely participate in pulmonary rehabilitation — a program of exercise and education that may help improve your breathing and daily functioning. Your team may provide training and education in many areas, including exercise, nutrition and breathing strategies.

Exercise program

Your treatment team will work with you to create an exercise program to meet your needs.

Your exercise program may include warm-up exercises, such as stretching or slow walking. Your treatment team may suggest physical activities such as walking, bicycling or strength training as part of your exercise program. Specialists in the treatment team will likely recommend that you cool down after you exercise, perhaps by walking slowly. Discuss with your treatment team what activities may be appropriate for you.

Take a break from exercising if you feel tired. If you feel symptoms such as shortness of breath or dizziness, stop exercising. If your symptoms don’t go away, contact your doctor.

References

1. Mooney JJ, Weill D, Boyd JH, Nicolls MR, Bhattacharya J, Dhillon GS. Effect of Transplant Center Volume on Cost and Readmissions in Medicare Lung Transplant Recipients. Ann Am Thorac Soc. 2016;13(7):1034-41. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015751/