What happens in the transplant assessment process?
Your lung transplant journey starts with a referral from your primary physician or referring pulmonologist. Our administrative team will connect you with our lung transplant pulmonologist. At this appointment, you will learn about your current health status and outlook in much greater and elaborate detail. After this appointment and your consent, the lung transplant pulmonologist will ask the transplant evaluation team to plan a transplant assessment. This process helps to determine if transplantation is the right treatment for you and ensures that it is as safe as possible for you to have a transplant. The assessment process will involve coming to the hospital to have a number of tests, and meeting with key members of your team. Having a lung transplant is a big decision. You need to understand the benefits, the risks, and our program requirements.
The assessment process will give you, your family and our team the information to make an informed decision about having a lung transplant. Once your assessment is complete, the transplant team will meet to review your results. This assessment process can take up to one week (7 days). Your transplant coordinator will call you to meet our specialists that includes pulmonologists, surgeons, intensivists, dieticians, psychologists, infectious disease specialists, transplant coordinators, physiotherapists and financial counselors to discuss the results of your assessment after the pre-transplant selection meeting.
If a transplant is recommended, the choice to proceed is up to you. We will support you whether you go forward with a transplant or not. While waiting on our list you decide to have a lung transplant you will meet with one of our transplant surgeons and your transplant coordinator to discuss your surgery and to sign surgical consent forms. Post financial clearance and psychological clearance, you are officially placed on the lung transplant waiting list by registering with Jeevandan/ZCCK TRANSTAN /NOTTO depending on your location of transplant. The time that you wait for your lung transplant is unpredictable because you have to be matched to a suitable donor. Our surgeons use several factors to match donors with patients on the waiting list. Two of the most important factors are: Blood type and lung size. Because of this, there is no “TOP” spot on the waiting list.
While you are waiting for your lung transplant there are three main goals:
1. Maintain your health and improve your strength. Our physiotherapy program will help you achieve this goal. The physiotherapists will also work with the doctors to ensure your oxygen needs are met.
2. Identify and manage any new and existing problems that may arise. We will partner with your family to manage your health. You and your support person will attend frequent appointments at our hospital.
3. Continue to learn about life with a lung transplant through our support and education groups and by speaking to your transplant team.
How is the surgery is performed, what are its steps?
Immediately before transplant, we will do a few tests and you will receive anti-rejection medications and antibiotics. There is a chance that the surgery will be canceled at the last moment as the team is assessing the donor lungs right up to the moments before the surgery. If the organ is found to be sub-optimal the call will be terminated, and you will be discharged home. It is not unusual for this to happen a couple of times. In the operating room, you will be given medication to keep you unconscious.
Several tubes are inserted into your body, including an endotracheal tube, which is a breathing tube that extends from your mouth into the lungs, an intravenous line in your neck, a nasogastric or “NG” tube that goes into your stomach through your nose, and a urinary catheter that drains urine freely into a bag. The surgery itself can take 8 or more hours depending on your condition and whether you have a double or a single lung transplant.
Some people need to have their lung or heart function supported by machines before, during, or after the surgery. Your chest will be opened between the ribs in the front across the breast bone or at the side. The diseased lungs will be removed and replaced with the donor lungs, one at a time. The new lung will be connected to the main bronchus, the pulmonary artery, and the pulmonary vein. After the lung is connected, the surgeons will leave drainage tubes around the lungs and heart and carefully close the layers of bone, muscle, and skin. After the surgery, you will be taken to the intensive care unit or ICU. You will remain there until you can breathe without the help of the ventilator, or breathing machine, and until your condition is stable.
What is organ rejection following transplantation?
The natural response in our body is to defend itself from harmful foreign substances like viruses and bacteria. In the case of lung transplantation, the donor lung is recognized as a foreign substance. Rejection is a process by which the body’s immune system attacks the transplanted lung, recognizing it to be different from your own tissues. You must take medicines to reduce your natural immune response and trick the body into accepting the new lung(s). However, even with these medicines, rejection can still happen.
Why does the body recognize the donor lung as 'different?
Your body's natural immune cells are able to recognize small, unique proteins called "antigens" that are present on the surface of all cells or infectious particles. These immune cells called the T cells and the B cells can recognize the antigens as "self" if they belong to you or "non-self" if they do not belong to you (such as those in the donor lung). This recognition occurs mainly through complex proteins on the cell surface called HLA antigens. The HLA system is made up of three classes with many subtypes, each person has a combination of these HLA proteins that makes him or her unique like a thumbprint, a signature. The differences in these signatures help our immune cells to separate "self" from "non-self".They then direct an attack on the foreign donor lung, resulting in "rejection".
What do rejection and infection entail in a post-transplant setting?
Two of the most common complications following the transplant are rejection of the lung and infections. Rejection is common and can happen any time after your transplant. Rejection happens because your immune system attacks your transplanted lungs. Your immune system sees your new lungs as invading cells and can damage them. To prevent this, you will take anti-rejection medications, also called immunosuppression medications. You will need to take these medications every day for the rest of your life to protect your new lungs.
Despite taking anti-rejection medications, rejection can still occur. It is often reversible as long as it detected and treated quickly. If the rejection is detected your treatment plan may include additional medications, adjusting your current medications, and other treatments.
Unfortunately, immunosuppressive medications also decrease the body’s ability to fight infection, and infections of the lungs are very common. Your weekly clinic visits will allow the transplant team to monitor for rejection and infection.
You will also need to:
• Perform home spirometry readings once daily and keep a record of your readings.
• Learn the signs and symptoms of rejections and infections and report any unusual symptoms to your transplant team right away.
The transplant programme will continue to monitor your health and will work closely with you and your support person, your family doctor, and your pulmonologist for the rest of your life. Your family doctor will continue to help you to maintain your general health and well-being. You will be assigned a transplant nurse coordinator and physician whom you and your caregivers can communicate with. Your team is there to help you, but it is important that you play an active role in maintaining your health and keep them informed about changes.
What are the different types of rejection?
Rejection can be classified by how the immune system attacks the donor lung and the time after transplant when it occurs. “Acute Cellular Rejection" occurs when your immune T cells directly attack the donor lung tissue. An “Antibody-Mediated Rejection" may occur where the recipient's B cells produce antibodies that attack the donor lung. These antibodies that develop in some patients can be detected by blood tests (called "donor-specific antibodies" or "DSA”. Cellular rejection is more common early on after transplant. Both of these types of rejection need to be diagnosed by a combination of clinical assessment, symptoms, and signs, testing such as spirometry, x-ray imaging, CT scans.