Complications - 1 Below is a list of some of the possible complications that one may encounter after lung transplant. Along with those complications, I have given some information on some of the current treatments. Acute Rejection Airway Complications - Bronchial Dehiscence: is the most common airway anastomotic complication in the early postoperative period - it occurs in 2-3% of cases. Ischemia at that anastomotic site is the major factor in development of this complication. Dehiscences smaller than 4mm, usually resolve without complication and do not require surgery.
- Stricture: Anastomotic stricture occurs in about 10% of cases and the risk for stenosis may be increased with a telescoping anastamosis. Stenoses often manifest with progressive airflow obstruction that can be difficult to differentiate from other causes such as bronchiolitis obliterans syndrome. Treatment is stenting, typically with an expandable metallic stent.
Aspergillosis - aspergillosis is caused by a fungas (aspergillus), which is found commonly growing on dead leaves, stored grain, compost piles, or other decaying vegetation. Also common in soil, and spores will become airborne in dry windy weather. Spores can not only enter and grow in the lungs, eys and ears, but also in moist areas of buildings and ventilation systems. -
Voriconazale - for treatment of invasive aspergillosis. -
Amphotericin B - Aerosolized amphotericin B lipid complex(ABLC) Amphotericin B - When introduced in 1959, amphotericin B deoxycholate (AmBD) was clearly a life-saving drug. Randomized studies demonstrating its efficacy were not thought to be necessary, and it was granted indications for many invasive fungal infections. Despite its formidable toxicities, AmBD is thus often used as the primary comparator in studies of invasive fungal infections. Safer lipid-based versions of amphotericin B (AmB) have been introduced, but difficulties with studying these agents generally led to licensure for salvage therapy, not primary therapy. However, the cumulative clinical experience to date with the lipid-based preparations is now adequate to demonstrate that these agents are no less active than AmBD, and, for some infections, it can now be stated that specific lipid-based preparations of AmB are superior to AmBD. Given their superior safety profiles, these preparations can now be considered suitable replacements for AmBD for primary therapy for many invasive fungal infections in clinical practice and research. (Source: Clinical Infectious Diseases, August 1, 2003) -
Flucytosine - treatment usual along with Amphotericin B -
Cancidas - IV drug, made by Merck & Co., Inc. - should not be used along with cyclosporine -
NEW DRUG - 12/2003 - Noxafil made by Schering-Plough Corp. Now being tested For More Information on Aspergillus http://www.aspergillus.org.uk/patients/New/welcomepages.php
Bacterial/Viral pneumonia: Bacterial pneumonias are the most common infection following lung transplantation and occur in greater than 35% of patients during the first year post-transplant(highest incidence is during the first month post transplant). The donor lung is more commonly affected. Viral pneumonias develop in about 11% of lung transplant patients and occur at any time following transplant. Adenovirus infection usually produces acute symptoms of lower respiratory illness, produces radiographic abnormalities and is associated with a very high mortality (60%).
Bone Density Loss - Pamidronate - (Aredia) - for Osteoporisis in patients with Cystic Fibrosis following lung transplant (IV therapy, approximately every 3 months)
Burkitt Lymphoma Arising in Organ Transplant Recpients - Rituximab may be an effective alternative to conventional combination chemotherapy in the treatment of a post transplant Burkitt lymphoma.(Source: The American Journal of Surgical Pathology, 2003)
Cold Sores (Herpes Simplex) - These sores look like tiney water blisters on the lip or face. You can use Blistex or simliar products on these. If they persist, you may need to take acyclovir. Let your transplant team know if you do develop these.
Cytomegalovirus - (CMV) - CMV disease is an opportunistic infection caused by the cytomegalovirus, which can complicate and interfere with transplants recipients' full recovery. FOR MORE INFORMATION - SEE THE FEATURE "CMV".
Diabetes - An important step towards minimizing the risk of developing new-onset diabetes after transplantation is the close monitoring of the two modifiable risk factors for new-onset diabetes, obesity and immunosuppressive therapy. In addition to counseling patients on the importance of weight control and physical activity, the guidelines recommend that clinicians carefully consider the selection of immunsuppressive agents, at the time of the introduction of immunosuppression and at any time thereafter that diabetes develops. New-onset diabetes after transplantation increases the risk of organ failure by 63%, increases the long- term risk of cardiovascular diseasae and increases the risk of death by 87%.
Epstein-Barr Virus (EBV) - Epstein-Barr virus, frequently referred to as EBV, is a member of the herpesvirus family and one of the most common human viruses. The virus occurs worldwide, and most people become infected with EBV sometime during their lives. In the United States, as many as 95% of adults between 35 and 40 years of age have been infected. Infants become susceptible to EBV as soon as maternal antibody protection (present at birth) disappears. Many children become infected with EBV, and these infections usually cause no symptoms or are indistinguishable from the other mild, brief illnesses of childhood. In the United States and in other developed countries, many persons are not infected with EBV in their childhood years. When infection with EBV occurs during adolescence or young adulthood, it causes infectious mononucleosis 35% to 50% of the time. Symptoms of infectious mononucleosis are fever, sore throat, and swollen lymph glands. Sometimes, a swollen spleen or liver involvement may develop. Heart problems or involvement of the central nervous system occurs only rarely, and infectious mononucleosis is almost never fatal. There are no known associations between active EBV infection and problems during pregnancy, such as miscarriages or birth defects. Although the symptoms of infectious mononucleosis usually resolve in 1 or 2 months, EBV remains dormant or latent in a few cells in the throat and blood for the rest of the person's life. Periodically, the virus can reactivate and is commonly found in the saliva of infected persons. This reactivation usually occurs without symptoms of illness. FOR MORE INFORMATION, SEE THE FEATURE "EBV"
Fungal Pneumonias in Transplant Recipients - Fungi are ubiquitous in the environment. Opportunistic fungal pneuonias in the immunocompromised host continue to increase most commonly due to Aspergillus. Affected patients are usually hematopoietic stem cell and lung transplant patients. Fungi are in the environment in such places as soil, water, food, plants, decaying matter. Small pores are easily inhaled and deposited deep in the lungs. Lung transplant recipients are a unique subset of patients susceptible to invasive aspergillosis in which the transplanted organ is continuously exposed to the environmental pathogens. Aspergillus continues to be the premier opportunisitic lung pathogen with multiple clinical presentations. In lung transplant recipients, the organism is mostly isolated in the first year after lung transplantation with an incidence of 29%. In patients with isolated tracheobronchitis, most patients(82%) respond to antifungal therapy and/or surgical debridement. Invasive pulmonary infection in certain immunocompromise patients is the most common fungal infection. Pseudoallescheria boydii is a ubiquitous filamentous fungus increasingly recognized as an opportunistic pathogen, more commonly in lung transplant. There is no consensus in fungal prophylaxis in lung transplant recipients. A signficant decrease in fungal infections was observed in patients with lung, heart/lung and heart transplants after prophylacitc administration of aersolized amphotercin B. (Source: Current Opinion in Pulmonary Medicine, 2003) (FOR MORE ON INFECTIONS, SEE THE FEATURE "INFECTIONS")
GI Complications are Common, Often Severe after lung transplantation - The most common nonpulmonary complications after lung transplantation are relate to the gastriointestinal(GI) tract and are associated with high morbidity and mortality, according to study findings. Records for 155 patients were reviewed. Forty-one percent of patients experienced GI complications and 20% of these patients underwent abdominal surgery, the researchers note. Of 69 post transplant deaths 11 (16%) were directly related to GI complications. Most cases of small bowel obstruction or gastroparesis occurred in patients with cystic fibrosis. It may be that these patients are experiencing damage to their vagal nerves when undergoing bilateral lung transplantation.(Source: InteliHealth, November 6, 2001)
High Blood Pressure (Hypertension) - Many transplant recipients will get high blood pressure from being on steroids or other immunosuppressive drugs. A combination of weight control, regular walking or other exercise and medication will help. Generally speaking, it is better if the systolic (or top number) is less than 140 and the diastolic(or bottom number)is less than 90.
Obese More Likely to Die after Lung Transplantation - Obese people are three times more likely to die after lung transplant than individuals at healthier weights, providing first time evidence that extremely heavy people should lose weight before having lung transplant surgery. University of Florida researchers discovered that the underweight patients had a superior survival rate - above 80 percent for the first four years after transplant, but survival rates fell to 50 percent after that time. Researchers were surprised to learn that patients who were overweight had similar survival rates as their normal-weight counterparts, who had rates as high as 90 percent in the first two years after transplant and 70 percent thereafter. Obese patients, however, experienced the lowest survival rates. After transplantation, their survival rates steadily fell to 30 percent at two years and beyond. Univeristy of Florida researchers theorize that increased respiratory demands and altered respiratory muscle mechanics caused by obesity led to the high mortality rates in obese lung-transplant recipients
OKT3 Toxicity - Is an antibody that binds to circulating T lymphocytes causing them to be opsonized by the reticuloendothelial system. The agent can produce pulmonary edema in some patients, typically within 6 hours of administration.(Source: Chest 1996)
Opportunistic Infection - Opportunistic infections are also common after lung transplant (34-59% of patients), but the infections do not seem to affect overall patient mortality. CMV is the second most common cause of pneumonia in lung transplant patients. Other less common causes of viral infections include herpes simplex virus. Patients with HSV infection present with fever, cough and dyspnea, but will demonstrate symptomatic improvement after therapy with IV acyclovir. Fungal opportunistic infections are less common than viral infection, but are associated with a higher mortality. Aspergillus infection is most commonly characterized by local invasion of a necrotic bronchial anastomosis typically found within 4 months of transplantation.
Parasitic Infection - Pneumocytis carini is an opportunistic protozoan that afflicts patients with impaired immunity. Pulmonary invasion often leads to progressive pneumonitis and respiratory insufficiency.
Pneumothorax - In the early postoperative period, recurrent pneumothorax tend to be the most common complication following lung transplants. Many are asymptomatic or mildly symptomatic and resolve spontaneoulsy. Yet, even a small pneumothorax affecting the transplanted side can be extremely symptomatic if the patient has severe contralaterail disease(such as cystic fibrosis)
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