Lung transplant

A lung transplant is an operation to remove and replace a diseased lung with a healthy human lung from a donor.

A donor is usually a person who's died, but in rare cases a section of lung can be taken from a living donor.

Lung transplants aren't carried out frequently in the UK.

When a lung transplant is needed

A lung transplant will often be recommended if:

• a person has advanced lung disease that isn't responding to other methods of treatment
• a person's life expectancy is thought to be less than 2 to 3 years without a transplant

Conditions that can be treated with a lung transplant include:

• chronic obstructive pulmonary disease (COPD) – a general term for a number of conditions that damage the lungs, usually as a result of smoking
• cystic fibrosis – an inherited condition that causes the lungs and digestive system to become clogged up with a thick sticky mucus
• pulmonary hypertension – high blood pressure in the blood vessels that carry blood from the heart to the lungs
• idiopathic pulmonary fibrosis – scarring of the lungs

Types of transplant

There are 3 main types of lung transplant:

• a 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
• a double lung transplant – where both lungs are removed and replaced with 2 donated lungs; this is usually the main treatment option for people with cystic fibrosis or COPD
• a heart-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.

Living donors

It's possible for a person to receive a lung transplant from living donors (2 living donors are usually required for 1 recipient). However, lung transplants from living donors are currently rare in the UK.

During this type of lung transplant, the lower lobe of the right lung is removed from one donor, and the lower lobe of the left lung is removed from the other donor. Both lungs are removed from the recipient and replaced with the lung implants from the donors in a single operation.

Most people who receive lung transplants from living donors have cystic fibrosis and are close relatives of the donors. The recipient and donors need to be compatible in size and have matching blood groups.

Preparation

Before being placed on the transplant list you'll need to have some tests to make sure your other major organs, such as your heart, kidneys and liver, will function properly after the transplant.

You may also need to make lifestyle changes, such as giving up smoking and losing weight (if you're overweight), so that you're as healthy as possible when it's time for the transplant to take place.

Read more about preparing for a lung transplant.

The lung transplant procedure

A lung transplant usually takes between 4 and 12 hours to complete, depending on the complexity of the operation.

A cut is made in your chest and the damaged lungs removed. Depending on your individual circumstances, you may be connected to a heart and lung bypass machine to keep your blood circulating during the operation.

The donated lungs will then be connected to the relevant airways and blood vessels and the chest will be closed.

A lung transplant is a major operation that may take at least 3 months to recover from. It could be quite a while before you're able to return to work so you'll need to make necessary arrangements with your employer.

Risks

A lung transplant is a complex type of surgery that carries a high risk of complications.

A common complication is the immune system rejecting the donated lungs. As a result of this, a medication known as an immunosuppressive is given to dampen the effects of the immune system, reducing the risk of rejection. However, taking immunosuppressives carries its own risks as they increase the chances of infection.

Outlook

The outlook for people who've had a lung transplant has improved in recent years and it's expected to continue improving.

The British Transplantation Society estimates that around 9 out of 10 people survive a lung transplant, with most of these surviving for at least a year after having the operation.

About 5 out of 10 people will survive for at least 5 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.

If a lung transplant is thought to be an option for you, you'll be referred for a transplant assessment.

Transplant assessment

You'll need to stay in hospital for up to 3 days for a lung transplant assessment.

Tests will be carried out to make sure your other major organs, such as your heart, kidneys and liver, will function properly after the transplant. These may include blood tests and any of the following investigations:

• a chest X-ray
• an echocardiogram – to check how well your heart is pumping
• an electrocardiogram (ECG) – which records your heart's electrical activity
• an angiogram – a type of X-ray that can be used to check the blood flow in the blood vessels of your lungs 

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

• surgeons
• anaesthetists
• 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 centre

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)

The waiting list

Once you're on the active waiting list, the transplant centre may give you a pager so you can be contacted at short notice.

The length of time you'll have to wait will depend on your blood group, donor availability and how many other people are on the list (and how urgent their cases are).

While you wait, you'll be cared for by the doctor who referred you to the transplant centre. They'll keep the transplant team updated with changes to your condition. Another assessment is sometimes necessary to make sure you're still suitable for a transplant.

Your transplant team will often be given short notice of donor organs, so will have to move swiftly. When a suitable donor is found, you'll usually need to be in hospital ready for your transplant within 6 to 8 hours. If you live a long way from a transplant centre, you'll be flown to the centre or taken by ambulance.

Getting the call

When a suitable donor lung is found, the transplant centre will contact you and ask you to go to the centre.

When you hear from the transplant centre:

• don't eat or drink anything
• take all current medicines with you
• take a bag of clothes and essentials for your stay in hospital

At the transplant centre, you'll be quickly reassessed to make sure no new medical conditions have developed. At the same time, a second medical team will examine the donor lungs.

The lung transplant must be carried out as quickly as possible to ensure it has the best possible chance of being successful.

A lung transplant usually takes between 4 and 12 hours, depending on the complexity of the operation.

After you've had a general anaesthetic, a breathing tube will be placed down your throat so your lungs can be ventilated.

The surgeon will make an incision in your chest so that your chest can be opened and preparations made to remove the diseased lung or lungs.

If assistance with your circulation is needed, a cardiopulmonary bypass machine may be used to keep your blood circulating during the operation.

The old lung will be removed and the new lung sewn into place. When the transplant team is confident the new lung is working efficiently, your chest will be closed and you'll be taken off the bypass machine.

Tubes will be left in your chest for several days to drain any build-up of blood and fluid.

You'll be taken to the intensive care unit, where more tubes will be attached to supply your body with medication and fluids and to drain urine from your bladder.

New surgical techniques

There are 2 new surgical techniques that will hopefully increase the number of donor lungs available for donation. These are described below.

Transplant after a non-heart beating donation

Most donations are from people who've died but whose heart is kept beating using life-support equipment. These are often people who've died following a long illness.

It's now also possible for lungs to be taken from a person who's died suddenly, and to keep their lungs "alive" for around an hour by passing oxygen into them. The oxygen keeps the biological processes of the lungs going, which preserves them.

Ex vivo lung perfusion

Lungs can be damaged when the brain dies, before they're removed for donation. As a result of this, only one in five lungs are suitable for donation.

Ex vivo lung perfusion is a new technique designed to overcome this problem. It involves removing the lungs from the body and placing them in a special piece of equipment called a perfusion rig.

Blood, protein and nutrients are then pumped into the lungs, which repairs the damage.

The technique is still in its infancy, but hopefully it will eventually lead to an increase in the number of lungs available for donation.

A lung transplant is a complex operation and the risk of complications is high.

Some complications are related to the operation itself. Others are a result of the immunosuppressive medication which is needed to prevent your body rejecting the new lungs.

Some of the complications are discussed below.

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 5 days after the transplant. These problems will gradually improve, and most people are free of symptoms by 10 days after their transplant.

Rejection

Rejection is a normal reaction of the body. When a new organ is transplanted, your body's immune system treats it as a threat and produces antibodies against it, which can stop it working properly. Most people experience rejection, usually during the first 3 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.

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 BOS, the 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

BOS 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).

PTLD 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.

PTLD affects around 1 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.

Infection

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

Long-term use of immunosuppressants

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

These health conditions are described below.

Kidney disease

Kidney disease is a common long-term complication. It's estimated that 1 in 4 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 5 years.

Diabetes

Diabetes, specifically type 2 diabetes, develops in around 1 in 4 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 8 out of 10 people after 5 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. 

After lung transplant surgery, you'll remain in the intensive care unit for around 1 to 7 days.

You may have an epidural (a type of local anaesthetic) for pain relief and will be connected to a ventilator to help your breathing.

You'll be carefully monitored so the transplant team can check your body is accepting the new organ. Monitoring will include having regular lung X-rays and lung biopsies (where tissue samples are taken for closer examination).

The transplant team will be able to see whether your body is rejecting the lung from the biopsy results. If it is, you'll be given additional treatment to reverse the process.

When your condition is stable, you'll be moved to a high-dependency ward, where you'll stay for 1 or 2 weeks.

Follow-up appointments

You'll probably be discharged from hospital 2 to 3 weeks after surgery and asked to stay near the transplant centre for 1 month so that you can have regular check-ups.

For the second month, you'll need to visit weekly for 4 weeks. After that, for the rest of your life, you'll have a blood test every 6 weeks and will be seen at the transplant centre every 3 months.

Getting back to normal

It usually takes at least 3 to 6 months to fully recover from transplant surgery. For the first 6 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 4 to 6 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 3 months after surgery.

Immunosuppressant therapy

You'll need to take immunosuppressant medications, which weaken your immune system so your body doesn't try to reject the new organ.

There are usually 2 stages in immunosuppressant therapy:

• 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
• 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
• diarrhoea 
• 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.

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 immunisations – your transplant centre 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 GP or transplant centre immediately if you have symptoms of an infection, such as:

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