Rejection & Infections

It is likely that at some time you may experience an episode of rejection. It is referred to as an episode of rejection because it is usually a temporary event. It will likely occur in the first six months of receiving your new heart, but it can happen at any time.

Rejection may occur even if you have been taking your medications faithfully. While you may find this thought disturbing, it is a common occurrence and should be expected. In most cases, with early detection and treatment, the transplant team should have no problem reversing the rejection completely.

The best ways to fight rejection are first, stop it before it starts, and second, recognize it and treat it early. You can work at preventing rejection by taking your medications properly. For early detection, learn to identify the signs and symptoms of rejection, and report them immediately to the transplant clinic nurse or doctor.

Signs of Rejection

Early identification and reporting of symptoms are important in successfully treating and reversing rejection. Most rejection episodes are mild. You may not have any symptoms, and may only be aware that rejection is occurring because it was detected with a biopsy. On the other hand, you may also start to feel symptoms of the rejection episode.

To ensure that the rejection is treated quickly, watch out for any of the following warning symptoms (these symptoms may feel somewhat like you felt before your heart transplant):

• decreased energy level
• reduced ability to exercise
• weight gain of one kilogram (2.2 pounds) per day, or more, sometimes with swelling of the ankles
• shortness of breath while doing normal activities
• irregular or fast heart rate
• low blood pressure

If you experience any of these symptoms, report it to your transplant team immediately. Of course it is better to report problems during the day, however you will have a 24­hour per day, 7 days per week contact number to report problems.

Heart Biopsies

At present, regular heart biopsies are the most reliable method of detecting rejection early. The heart biopsy takes about 10 to15 minutes and is a safe and relatively painless procedure done in a specialized laboratory. The heart biopsy is arranged through the transplant clinic.

Treatment of Rejection

When rejection is detected, it must be treated immediately. Most people are admitted to the hospital for about three days for their first episode. Treatment usually involves high doses prednisone (or steroids), which can be taken either intravenously (through a vein), or by an increase in prednisone tablets. In most cases, this will reverse the rejection.

Rejection is divided into 6 grades:

• No rejection
• 1a Minimal rejection – no treatment necessary
• 1b Mild rejection – usually not treated
• Mild, moderate rejection – usually treated with tablets
• 3a Moderate rejection – treated with tablets or IV injection
• 3b Moderate –severe rejection – treated with IV injection
• 4 Severe rejection – treated with IV injection

Chronic Rejection (otherwise known as transplant coronary artery disease)

Transplant coronary artery disease sometimes occurs in a transplanted heart. While doctors are unsure what causes it, it appears to be related to the immune system and is believed to be a form of chronic rejection. This disease occurs in approximately 20­-40% of heart transplant patients after one year. It is usually mild. Only the most severe cases may require major treatment.

The treatment varies and may include drug therapy, angioplasty (a balloon to open the blockage), bypass surgery and very occasionally a second transplant. Because of the loss of heart nerves during surgery, there is a chance you may not experience the chest pain that would normally warn you of a problem. It is therefore important to monitor your heart and arteries with routine testing as described above.

A healthy diet low in salt (or sodium), cholesterol, and fats is highly recommended for all people, and particularly for transplant recipients. Your cholesterol level is monitored regularly. You will also be placed on drugs that lower your cholesterol.

Watch Out For Infections

A possible side effect of anti­rejection drugs is an increased risk of infections. While weakening the immune system is necessary to prevent rejection of your heart, it lowers the body’s ability to fight off infections. Fortunately, there are ways of reducing the risk of getting an infection while still being able to prevent rejection.

The risk of contracting an infection is higher during the first few months following a transplant when your doses of anti­rejection drugs are higher. As the doses are lowered, the risk of infection falls. As with rejection, the key to fighting an infection is to prevent it, identify it early, and treat it quickly.

Preventing Infection

The best way to prevent an infection is by avoiding close contact with people who have them. Most infections are passed from person to person in tiny water droplets and may be transferred simply by shaking hands. Someone sneezing or coughing is sending out droplets, which you might breathe in, or transfer to your mouth with your hands.

During the first few months following your transplant, you must be careful in avoiding infections. This may mean having to avoid close contact with family members if they are sick. It is not possible to move out of your house if someone who lives there has a cold, so avoiding close contact means:

• Do not kiss a person a cold or get very close. If anyone in your house has a cold, you may have to sleep separately until the coughing/sneezing stops.
• Encourage the person with a cold to cover their nose and mouth with a Kleenex or handkerchief when coughing or sneezing.
• Do not visit people who have a cold.
• Wash your hands regularly and avoid shaking hands and contact with people.
• Avoid crowded, poorly ventilated, smoke-filled rooms (always).
• Avoid public transportation and public swimming pools
• Don’t undertake activities that may cause you to inhale dusts – wear a dust mask when sanding back paint, gardening in dry, dusty conditions or any other very dusty activity
• Wear a mask initially if people are around.

Signs of Infection

Early detection is essential to the successful treatment of infection; Therefore, it is important to report any symptoms immediately to your transplant team.

Symptoms of infections can be:
• A temperature above 37.5° C (99° F) ; if your temperature is high, take it a second time in one hour, before calling
• coughing up green or yellowish sputum, or a dry cough
• a burning or stinging sensation when you urinate, or a pink tinge to the urine
• sores anywhere on the body, including cold sores
• any redness, swelling, discharge, or pain around your incision, or around any cut or scrape
• nausea, vomiting, diarrhea
• pain in the stomach
• neck stiffness accompanied by headache

If you have any of these symptoms, report them to your doctor immediately. The sooner you detect infections, the easier they will be to treat.

Cancer.

Certain types of cancer, particularly skin and lymph node cancer, are a possible complication of the long-term use of anti-rejection drugs. These drugs, while altering your body’s immune system to prevent rejection, may leave you more vulnerable to other diseases, including certain types of cancer. The most common treatment for lymph node cancer is reducing the doses of your anti­rejection drugs and letting your immune system fight off the cancer. Any new skin spot or change to a mole should be reported to the doctor and transplant clinic nurse. You should be referred to a dermatologist when you are settled back home. You should see them at least once a year for the rest of your life.

Related Links
Going Back Home – Do’s & Don’ts
Things You Need to Know Post Transplant
Lungs
Intestines
Pancreas

References:
Fortis Memorial Research Institute
www.medanta.org
http://www.bhf.org.uk/