Your immune system seeks out and destroys things that are not supposed to be in your body. It protects you from getting sick. The immune system will also attack the transplanted lung because this lung is not genetically identical to you.When the immune system attacks the transplanted lung, you have rejection.In order to keep the immune system from rejecting and destroying the transplanted lung, we must give you immune suppressant (medicines that suppress the immune system). These medicines make your immune system weaker, which should slow down or prevent rejection, but can also make it easier to catch infections, even simple viral infections.
Types Of Rejection
Acute rejection of the transplanted lung can happen at any time. Usually episodes of acute rejection happen during the first month after the transplant.Acute rejection episodes are expected. Other than taking your medicines, there is nothing you can do to prevent this from happening.
The following are signs of rejection:
- Temperature of more than 99.5 degrees
- Increasing fatigue or generalized weakness
- A decline in your lung function (FVC/FEV1)
- Shortness of breath
These signs of rejection need to be promptly reported to your doctor for diagnosis and treatment.
Bronchiolitis Obliterans (Chronic Rejection)
Bronchiolitis obliterans is thought to be a form of chronic rejection. It eventually occurs in approximately 50% of all lung transplant recipients. Small airways become plugged with scar tissue, decreasing air flow. The cause of bronchiolitis obliterans is not known. It is most often irreversible. However, if it is treated soon enough, lung function is sometimes maintained or, more rarely, recovered.As bronchiolitis obliterans gets worse, the patient may need oxygen. Exercise tolerance may decrease. Rarely, re-transplant may be considered.
The immunosuppressant medicines given to prevent rejection will decrease your ability to fight infections. The ability to fight infection is inversely related to the amount of immunosuppression you take. The highest doses of immunosuppression are given immediately after your transplant and for the next three months.During this time you are at the highest risk for catching an infection.
While you are in the hospital, the team will protect you from some infections by using protective precautions, a form of isolation. You will be in a private room. Visitors and staff will wear masks for the first two days. You will wear a mask when you leave your room. Family and friends with colds or flu may not visit. Fresh flowers are not allowed; Balloons and artificial flowers or plants should be sent instead. Uncooked vegetables are not allowed. You may eat uncooked fruit if it can be peeled, like bananas and oranges.
After you leave the hospital, a mask is not necessary every time you leave your apartment or home. You should wear a mask in higher risk areas such as the hospital, physical therapy, and clinics; working in the yard or flying in a commercial air plane; or occupying other confined, enclosed spaces like a bus or train.Exposure to freshly dug earth or mulch since they contain fungi which can be particularly dangerous to the transplanted lungs.
Your lung is the most likely place to catch an infection after your transplant.Chest X-rays will be done regularly and whenever you are ill, to look for infection in your lungs. Other common infections after transplant may happen in the urinary tract, mouth, sinuses, or blood.
Your body’s natural ability to heal wounds will be slower, due to the prednisone you take after transplant. It is important to keep cuts or other injuries clean and dry. If healing takes a long time, or if pain and swelling become a problem, you need to call your doctor or transplant coordinator immediately.
Good care of your teeth is important because the mouth has a lot of bacteria.You should see your dentist every six months. To prevent infections, you will need to take antibiotics before and after having any dental work such as cleaning,extraction, or gum work. Be sure to tell your dentist about your transplant,and contact your transplant coordinator before your appointment so a prescription can be written.
Avoid smoke-filled areas and ask people not to smoke around you. Smoking is a cause of heart and lung disease. Even second-hand smoke can make it easier to catch lung infections.
Signs of an Infection
- The following are signs of infection:
- Productive cough, change in the colour of sputum, shortness of breath
- Fever greater than 99.5 degrees, chills
- Pain or burning with urination
- Nausea, vomiting, diarrhoea, abdominal pain
- A decrease in FVC, FEV1, or FMID of 10%
- Sinus pain, drainage, or post-nasal drip
- Fatigue or decreased exercise tolerance
These signs should be promptly reported to your transplant team.
Common Viral Infections
Common colds and many other illnesses can be caused by viruses. While it is impossible to protect the transplant patient from all viruses, flu shots and pneumonia vaccines are recommended. They should be given when the immune suppressing medicine doses are lowered. Most viral illnesses will not cause problems for your transplanted lungs. Some viruses though can result in an acute rejection episode. If you feel ill, you need to tell your doctor or transplant team immediately.
Cytomegalovirus (CMV) is a common virus, belonging to the Herpes virus family. Over 50-80% of the general population has already had CMV. Most young adults will have antibodies to this virus. CMV does not usually cause problems for patients with normal immune function. After transplant, CMV can make you quite ill.We test you for CMV during your transplant evaluation, at the time of your transplant and routinely thereafter. Your donor is also tested for CMV. You can get CMV from your donor, your previous infection with CMV (called reactivation), or other people in the community. CMV infections can happen at any time; however,they usually occur in the first three to six months after transplant, when you are taking the highest doses of your immune suppressing medicines. If you are diagnosed with a CMV infection you will be prescribed medications to treat the infection.
Epstein – Barr virus (EBV) is the mononucleosis virus, which most people get sometime before turning 30 years old. You are tested for EBV during your transplant evaluation. If you have had EBV before your transplant, you are well protected from getting sick from this virus after your transplant. If you have not had EBV before your transplant, you will probably get this virus after your transplant either from your donor or from blood transfusions.
EBV infections may result in post-transplant lymph proliferative disease (PTLD).PTLD is enlargement of the lymph nodes, usually found on a routine chest X-ray,on your tonsils, or under your armpits. If you have not had EBV before your transplant, your chest X-ray will be checked every couple of weeks. A blood test for EBV will also be checked frequently to watch for this virus. If you get EBV after your transplant, we will make changes in your immune suppressing medicines to help your body better fight the virus.
Common Fungal Infections
Candida is common yeast. Candida most frequently causes thrush in the mouth.Mouth thrush is evidenced by white, round, painful spots in the back of the mouth or on the tongue. Thrush can also progress all the way down the throat and oesophagus. Nystatin mouth wash is prescribed to help prevent thrush.Candida can also infect moist skin folds, such as in the groin or under the breasts. Vaginal yeast infections may also occur. Nystatin powder or cream may help clear up these infections. Candida infections outside the mouth are rare, unless you are taking antibiotics.
Good skin care without using heavy powders or perfumes will help prevent Candida infections on the skin. Douching is not recommended for women. Eating yogurt with active cultures while taking antibiotics may help prevent yeast infections.Do not use medicines to clear up yeast infections without first checking with your transplant team.
Aspergillus is a common fungus found in dirt and dust. Your best protection from getting a serious infection from Aspergillus is to wear a snug mask when near construction sites or the hospital. You should always wear a mask while working in the yard. Avoid fresh earth, mulch, digging, or working in crawl spaces or attics. Light housekeeping should not be a problem.
After your transplant, you will take many different medicines to help prevent rejection and infections. Other medicines may be given to counter side effects,such as high blood pressure, or to prevent ulcers. Many medicines interact with each other and can change the way other medicines work. Medicine such as ibuprofen or any non-steroidal anti-inflammatory drug can have serious interactions with the other medicines you are taking. Always check with your transplant team before taking a new medicine or herbal remedy,whether it is prescribed by a doctor or can be bought over the counter.When taking a vacation, remember to pack enough medicines for your entire trip, plus some extra, just in case your travel plans change. All of your medicines must be packed as carry-on luggage to help prevent loss. Not all pharmacies routinely carry these medicines.
Immunosuppressant is the medicines which help prevent the body from rejecting the transplanted lung. These medicines work by lowering the number of white blood cells and changing the way the white blood cells work. While these medicines help prevent rejection, they will also lower your ability to fight infections.
All signs and symptoms of infection, such as fever, chills, more mucous production,fatigue, nausea and vomiting, must be reported as soon as you notice them. An infection that occurs while taking medicines that lower the immune system must be treated promptly to prevent additional problems. You also will need to be careful in your personal hygiene. Good hand washing is the best protection from catching infections of all kinds. Daily care of your teeth is necessary to prevent infections of your teeth and gums. Regular check-ups with your dentist are also important. Be sure to tell your transplant coordinator or doctor before you have your teeth cleaned so that an antibiotic can be prescribed.
When having blood work done, always hold your immunosuppressant medication until after your labs have been drawn. Then take your morning doses as scheduled.Check with your transplant coordinator prior to your evening dose of immunosuppressant medication to make sure your blood levels were okay and that no changes to your dose are necessary. Make sure your lab work is scheduled to coincide with your morning medication dose time.No one medicine can prevent rejection alone. Most patients will take a combination of three medicines.
Reasons For Transplant
Lung Transplant Evaluation, Allocation, Scoring & Matching
Waiting For An Organ Donor
Getting The Call
The Lung Transplant Operation & Post-Operative Stay
Clinic Visits & Studies