Lung Transplant

On behalf of Inova Advanced Lung Disease and Transplant team, welcome. Transplantation is like no other procedure in terms of meticulous planning. Unlike popular TV shows, it doesn't happen overnight in hospital emergency rooms!

Our team carefully completes a series of important steps to ensure that patients are appropriate candidates and are well prepared for transplantation. This care and precision, we believe, is reflected in our higher-than-average survival statistics. Our most recent statistics show Inova lung recipients have the following survival rates: 1 month – 100% (with expected probability adjusted for patient and donor at 97.47); 1 year – 91.09% (with adjusted of 88.89) and 3 years – 66.67 (with adjusted of 70.26).

We also believe education is a key component to the preparation process because patients who are better informed tend to deal with post-transplant demands more successfully. Knowledge is empowering and demystifying for both patients and their caregivers.

We hope you'll explore this site with your family and friends and contact us if you need more information. Referring physicians, you may contact us at any time.

• Patients call 703-776-2986
• Physicians call 703-776-6168

After discharge from the hospital, you will be seen regularly in the lung transplant clinic by a post-transplant nurse practitioner or a transplant pulmonologist.

The frequency of your visits depends on when you received your new lungs and your overall medical condition. Expect twice-weekly visits during the first month after transplant. In addition to monitoring your physical condition, we will provide as much information as possible to you and your family to facilitate your return to an independent and fulfilling life.

Caring for new lungs is a lot of work. Once discharged from the hospital, each day you will monitor your temperature, blood pressure, weight, lung function (through daily microspirometry sessions) and possibly blood sugar.

You must carefully follow your daily medication schedule and participate in at least 6 pulmonary rehabilitation sessions. We will schedule you for routine bronchoscopies about every 3 months during the first year so your pulmonologist can monitor the health of your new lungs by checking for infection and rejection.

Temperature

Take your temperature twice a day, before breakfast and before dinner. Record the results in your daily record. Also, take your temperature any time you feel chilled, hot or achy, as this may be the first sign of infection or rejection. Contact the transplant team if your temperature ever exceeds 99 degrees F.

Blood pressure

Take your blood pressure in the morning before breakfast and before dinner and record the results in your manual. Notify your transplant team if your blood pressure is:

• Systolic (top number) greater than 180 or less than 100
• Diastolic (bottom number) greater than 100 or less than 50

Your blood pressure machine also takes your pulse. Notify the transplant team if your pulse is greater than 140 or less than 60.

Weight

Weigh yourself every morning after you urinate and before you eat breakfast. Notify your transplant team of any weight gain greater than 3 pounds in a 24-hour period.

Lung function

While you are still in the hospital, you will be instructed to purchase an at-home microspirometer to check your lung function twice a day. Read further instructions below.

Once home, measure your FEV1 and FVC every day at the same time and record the numbers in your daily record. You will also receive an incentive spirometer and acapella for airway clearance. Use these 3 times a day during the initial post-transplant period following discharge.

Notify your transplant team if either your FEV1 or your FVC decreases by 10% for 2 days.

Blood sugar (diabetics only)

If you were diabetic before your transplant or have developed diabetes since your surgery, you will need to monitor your blood sugar 3 to 4 times daily. Record the results in your daily record. Notify the transplant team or your endocrinologist if your blood sugar is less than 60 or greater than 350.

Bronchoscopy

This valuable monitoring and diagnostic test is performed for a number of reasons. Read more below. 

Bronchoscopy is another tool for monitoring and diagnosis. A bronchoscope is a thin, long instrument equipped with a light and camera. It is inserted into a sedated patient's airways and lungs to examine for abnormalities and rule out infection and rejection.

Bronchoscopy is performed by a pulmonologist. The procedures takes place in the bronchoscopy suite located adjacent to the pulmonary function laboratory at Fairfax Inova Hospital. There are two types of bronchoscopy procedures.

• Surveillance bronchoscopy is performed on a routine basis following transplantation to ensure there are no underlying problems with your new lungs. We generally will schedule you for a bronchoscopy between 7 and 10 days after your transplant and again at 1 month, 3 months, 6 months and possibly 9 and 12 months following transplantation.
• A clinically-indicated bronchoscopy is performed when a patient's condition changes and the physician needs to know what is happening in the lungs. Symptoms that may necessitate a bronchoscopy include shortness of breath, a drop in lung function numbers, a change on a patient's X-ray or unexplained fever.

Depending on timing, a clinically-indicated bronchoscopy may replace the next routinely-scheduled surveillance bronchoscopy.

Before a bronchoscopy

Do not eat or drink anything prior to your bronchoscopy without first talking with your physician/NP. You may take your medications with sips of water. Bring your medicine with you to take after the procedure.

Consult with your phsician/NP prior to your procedure if you take a blood thinner or medication for blood pressure or diabetes.

Arrange for a family member or friend to accompany you to the procedure and to remain in the waiting area during the procedure. You can return home after your bronchoscopy but will be drowsy and unable to drive.

The procedure
Bronchoscopies are usually done under general anesthesia. Bronchoscopy is generally not a painful procedure.

The trachea is entered and both sides of the lung are inspected in detail. The physician uses the bronchoscope to suction out any secretions. Sterile fluid is put into the lung and then suctioned out into a collection container.

The specimens collected are called bronchial washings or bronchoalveolar lavage. These fluids are sent to the microbiology laboratory to check for viruses, bacteria or fungi which may require treatment and for abnormal cells (cytology).

Close attention is paid to the bronchial anastomosis, which is the hook-up between the native bronchus and the donor bronchus. The physician looks for scar tissue or stricture formation.

A biopsy (tissue sample) of the lung is usually obtained, especially if rejection is suspected. The physician passes biopsy forceps through the bronchoscope into the lung and collects tiny snips of lung tissue by opening and closing the forceps. The physician uses fluoroscopic (X-ray) guidance to ensure that the forceps are properly positioned.

Complications
Complications from biopsies may include bleeding or pneumothorax (also known as a collapsed lung). Bleeding is controlled through suctioning or by passing medication such as epinephrine through the bronchoscope to constrict the bleeding vessel(s). You may cough up a little blood for up to 24 hours.

You will have a chest X-ray after the bronchoscopy. A pneumothorax is trapped air between the lung and the chest wall. Depending on the size of the pneumothorax, a chest tube may be inserted to evacuate the air. You may also develop a low fever after the procedure. Contact your transplant coordinator if your symptoms worsen or persist for more than 24 hours.

Biopsy results
Lung tissue biopsies are graded on a scale of 0-4. Zero (0) means no rejection. Four (4) means severe rejection. Your pulmonologist will review the biopsy with a pathologist and evaluate all of your symptoms to determine the best course of treatment for you. Biopsy results are usually available the next day.

We follow our post-transplant patients very closely and will see you frequently in the lung transplant clinic after your surgery. Outlined below are our general clinic guidelines, but a sudden change in your condition may warrant additional unscheduled tests such as chest X-rays, CAT scans, 6 minute walk test (6MWT) to detect activity-related low oxygen levels, blood work, spirometry, or bronchoscopy.

We make every attempt to maintain an efficient clinic schedule and to see you at your scheduled time. However, lung transplant patients who present with unexpected complications require the care of multiple providers and may need to be seen ahead of waiting patients. Be assured that you will receive our full attention once it is your turn to be seen.

Our clinic patients can develop various infections. There is no reliable way to isolate sick patients from well patients in the waiting area. Always wear a mask for your clinic visits 4 to 6 weeks after transplant.

Frequency of visits

After you are discharged from the hospital, we will see you in the clinic for a visit twice a week for the first month. If clinically stable, your appointments will be scheduled as weekly visits for 1 month, every other week for 3 months, monthly for 3 months and then once every 3 months after the first year. If there is a change in your condition we will need to see you between routine appointments.

Hours of operation

The post-transplant clinic sees patients from 9 a.m. to 4 p.m., Monday through Friday.

What happens during the visit

Regular appointments include spirometry (done at our clinic or pulmonary function lab), blood work (done in our clinic) and a clinic visit with our staff. A chest X-ray (performed in the Radiology department) may be requested as well.

A nursing assistant will check your vital signs and do blood work. The transplant coordinator will review your vitals in your daily record and confirm that you are taking your medications appropriately.

The transplant nurse practitioner or pulmonologist will perform an exam, review your studies, discuss any problems you may be experiencing and make any needed changes to your care plan. At the end of your visit, staff will confirm your next appointment.

Before your visit

Do not take your morning dose of immunosuppression (Prograf, Cyclosporine, Rapamune, Everolimus) or antifungal (posaconazole, voriconazole, itraconazole) before your blood is taken. We routinely test for complete blood count (CBC), chemistries, immunosuppression and antifungal levels and CMV infection. Blood test results are usually available the same day as your visit. We will notify you by telephone if your test results indicate a need to change your regimen.

Important reminder

Please bring your medication list and daily records with your vital signs and spirometry with you to every visit.

Spirometry is one of the ongoing pulmonary function tests (PFTs) we use to monitor lung function following transplantation. As you know, vigilance is a key to success in lung transplant patients, and spirometry is one of the simplest and best tools we have to catch even small changes in lung function.

Spirometry is routinely performed at each of your clinic visits, but you will need to also measure your lung function at home every day. You will receive your own personal portable microspirometer, and instructions how to use it, before leaving the hospital.

The maneuver

To perform a spirometric maneuver, take in as deep a breath as possible and then blow out as hard and as long as possible through your mouth into the microspirometer. You must maintain a tight seal between your mouth and the mouthpiece. We also recommend you wear a nose clip for best results. The goal is for every molecule of your exhaled breath to be captured by the microspirometer.

The home spirometer records two numbers. Forced vital capacity (FVC) represents the total volume of air blown out. Forced expired volume in 1 second (FEV1) represents the amount of air blown out in the first one second of exhaling.

Perform 3 maneuvers at the same time each day and record the highest FVC and FEV1 readings you obtain, even if they come from different maneuvers. Note that the readings obtained at home may run a little lower than those recorded in the PFT lab.

Call the Lung Transplant Center if you experience a drop of 10% in either of the numbers over 2 days time. Depending on your situation, you may be asked to come to the PFT laboratory for further testing.

Your physician will prescribe several medications which you will need to take regularly for the rest of your life. The transplant team will provide you with detailed information about how and when to take your medication.

Transplant patients generally receive a 3-drug regimen including a calcineurin inhibitor (cyclosporin (CSA) or tacrolimus), a purine synthesis inhibitor (mycophenolate mofetil (MMF) or azathioprine (AZA)) and corticosteroids.

The following information about immunosuppressive drugs is detailed and quite technical. Feel free to talk to the transplant team about your medication and any side effects you may experience. Also, keep in mind that each transplant patient responds differently to medication. It is unlikely you will experience all of the side effects listed here.

Cyclosporin A (CSA, Neoral, Gengraf, Sandimmune, Eon)

The major cyclosporin side effects include nephrotoxicity (kidney problems), which occur in one-third of patients. Fluid retention (swelling in feet and legs), high potassium and chloride levels may accompany elevated creatinine levels. It is often associated with high trough levels, and is mostly reversible upon dose reduction.

Hypertension, both systolic and diastolic, occurs in 50% of patients and usually develops within few days to a few months after CSA administration. Neurotoxicity, including headaches and fine hand tremors, occur in 1 in 3 patients and may improve without stopping therapy.

Peripheral neuropathy with symptoms of numbness, tingling and burning may also occur, as can mild alterations in mental status. Seizures, when CSA is used with high-dose steroids, have been reported.

Mild hirsutism (increased hair growth) on the face, arms, eyebrows and back occurs in 1 in 3 patients. Gingival hyperplasia (swelling of gums) occurs in 1 in 10 patients and may improve with vigorous oral hygiene.

Tacrolimus (FK506, Prograf)

A side-effect profile of Prograf is similar to CSA and includes similar rates of nephrotoxicity (kidney problems), neurotoxicity (tremor, headaches) and hypertension. Unlike cyclosporin, it can also cause diabetes mellitus and may need to be replaced by cyclosporin in patients with difficult-to-control diabetes.

Azathioprine (AZA, Imuran)

Major side effects of azathioprine include hematologic toxicity, temporary hair loss, hepatotoxicity, pancreatitis, rash and gastrointestinal (GI) side effects. Hematologic toxicity manifests as dose-dependent low white blood counts, although all bone marrow lines may be suppressed.

Liver function abnormalities may require dosage decreases or discontinuation of the medication. Other infrequent side effects include rash, nausea and vomiting. AZA should never be taken with allopurinol (medications for gout), as the combination can cause severe bone marrow suppression.

Mycophenolate mofetil (MMF, Cellcept)

Potential toxicities of MMF include low blood counts and GI side effects such as nausea, vomiting and diarrhea. GI side effects may be reduced by splitting the daily dose into three or four smaller doses. Sirolimus (rapamycin, Rapamune) can cause high triglycerides and cholesterol in a dose-dependent fashion.

It can also result in bone marrow suppression with low blood counts, especially when used with MMF. Low potassium levels, rash, nausea and vomiting have been reported.

Corticosteroids (prednisone, prednisolone, deltasone)

Prednisone toxicities are numerous and include high blood sugars and increased appetite, fluid retention, high blood pressure, cataracts, mood alterations, increased risk of infections, musculoskeletal symptoms and osteoporosis. Efforts are usually made to reduce the steroid dose as quickly as possible  because of its multiple side effects.

According to the International Society of Heart and Lung Transplantation (ISHLT), just over 4,600 lung transplants were performed world wide in 2016.

Survival for all lung transplant recipients was analyzed. Benchmark survival rates were:

• 88% at 1 year (in the US)
• 72% at 3 years (in the US)

Survival depends on many factors, including the pre-transplant diagnosis, recipient age, weight and overall health, type of transplant, various donor characteristics and other factors.

More than 80% of patients had no activity limitations at 1, 3, 5 and 10 years after transplant.

Lung transplantation is a complex procedure and complications do occur during and following surgery. Many of the complications outlined in this section are the direct result of the critically-important immunosuppressive medications you need to take as a transplant recipient.

We want you to be aware of these potential complications. At the same time, we are fully committed to minimizing or preventing complications whenever possible. Please come to us with your questions and concerns.

Your body's immune system protects you from foreign substances such as bacteria, fungus and viruses that can cause infection.

Unfortunately, your immune system identifies your newly-transplanted lung(s) as a foreign substance and goes to work fighting off this intruder.

When your body's immune system attempts an attack, it is called rejection. Almost everyone develops rejection at some time. You will take immunosuppressive medications to fool your body and to prevent your immune system from attacking and damaging your new lung(s).

Rejection usually occurs in the first 6 months after transplantation, but it can occur at any point, especially if you do not take your medications correctly. This is one of the reasons we schedule you for frequent visits to the post-transplant clinic.

Learn the signs and symptoms of rejection. If you experience any of the following signs and symptoms of rejection, report them to your transplant team immediately:

• Fever
• Fatigue or weakness
• Shortness of breath
• Decrease of 10% in FEV1 or FCV readings over 2 days

A bronchoscopy with lung biopsy is used to confirm rejection and/or an infection.

Your transplant team has many medications available to treat rejection. Treatment is usually given intravenously and includes higher doses of steroids or other medication. Depending on your situation, you may receive your treatment at home or in the hospital.

The heart is the "bridge" between the lungs and the rest of the body. Both organs sit in the chest cavity with the heart surrounded by the lungs. The right side of the heart receives blood from the body and pumps it into the new lung. The new lung provides oxygen to the blood and removes carbon dioxide. The blood is then returned to the left side of the heart and pumped out to the rest of the body. As such, the heart and lungs function in tandem to supply and deliver oxygen to the rest of the body.

Despite this close relationship, long-term heart problems after a lung transplant are rare. The transplant team carefully screens for pre-existing heart disease prior to transplant to minimize problems.

You may, however, experience heart-related problems immediately following transplant. You will receive medication to counter low blood pressure, a common problem which occurs due to blood loss, dehydration, coming off the heart-lung machine or a shift in the heart's position within the chest cavity.

Arrhythmias (irregular heartbeats) may also occur post-operatively but usually are short lived and easily controlled with medication. Some patients take medication for arrhythmia on an ongoing basis.

Despite close scrutiny of the heart vessels prior to transplantation, myocardial infarctions (heart attacks) can still occur during or soon after the transplant procedure. This may be precipitated by prolonged low blood pressure or low oxygen levels.

Some of the immunosuppressive agents (steroids, tacrolimus, cyclosporin, rapamycin) can boost blood cholesterol and triglyceride levels. Patients may need a lipid-lowering agent as one of their long-term post-transplant medications. Interestingly, statins (a class of cholesterol-lowering agents) have been shown to decrease the incidence of rejection and are frequently taken by transplant recipients.

Infrequently, elevation of pressure in the lungs (pulmonary hypertension) may develop in the post-transplant period.

Bronchiolitis obliterans (BO) is more commonly known as chronic rejection. Between 25% and 50% of lung transplant recipients experience BO.

Its cause is unknown but may be related to previous episodes of acute rejections or infections. There is no specific cure for BO, but there are therapies that may stop or reverse its course. Your physician will discuss an individualized plan of care if you develop chronic rejection.

Chronic rejection is characterized by a narrowing and disintegration of the small bronchioles. These are the smallest of the airways through which air travels into and out of the alveolar sacs. The alveolar sacs are where gas exchange (oxygen taken up and carbon dioxide eliminated) occurs within the lungs.

Symptoms of chronic rejection include a drop in spirometry levels and subsequent shortness of breath. Patients who develop chronic rejection are also at greater risk for lung infections.

A bronchoscopy with biopsy is performed to diagnose chronic rejection. Some of the other conditions which need to be ruled out include airway complications, infection, acute rejection, congestive heart failure and pulmonary hypertension.

Because the cause of BO is unknown, in 1993 the International Society for Heart and Lung Transplantation coined the term "bronchiolitis obliterans syndrome" (BOS) to describe deterioration of lung function for which there is no other identifiable cause. Patients have BOS if there is a 20% reduction in their FEV1 (forced expired volume in 1 second) from their previously established baseline.

Unfortunately, chronic rejection is a difficult condition to treat. There are several medications shown to arrest or stabilize progression of the condition. Radiation therapy has also shown to be effective. New medications currently in clinical trials hold promise for improvements in future treatment and prevention of chronic rejection.

The gastrointestinal (GI) tract is often the "spoiled child" of transplantation recipients because it tends to act up when the recipient is otherwise feeling well.

GI problems are usually medication related or signal an infection. If GI upset is accompanied by a fever, it is more likely to be infection related. GI upset can be characterized by one or all of the following:

• Nausea
• Vomiting (If unable to hold down medications, contact the transplant team. IV fluids or medication may be required.)
• Diarrhea
• Stomach cramps

The most common drugs used post transplant that may result in these symptoms include:

• Cellcept (mycophenolate mofetil)
• Prograf (tacrolimus, FK506)
• Cytovene (ganciclovir)
• Fosamax (alendronate)

Infectious agents affecting the GI tract

Clostridium difficile colitis (C.diff) most often affects patients who recently have taken large doses of antibiotics. Symptoms include diarrhea, which can be explosive and foul smelling, fever and occasionally vomiting.

C.diff also can have the opposite effect and cause a paralysis of the GI tract. On rare occasions this can cause extreme dilation of the colon or a so-called toxic megacolon, which can be life threatening.

C.diff is referred to as pseudomembranous colitis because it is characterized by plaques in the GI tract that resemble membranes. A stool sample generally sufficient for diagnosis, but sometimes a gastroenterologist will perform a sigmoidoscopy or colonoscopy to view the interior of the rectum and colon. C.diff is effectively treated with antibiotics (vancomycin or Flagyl).

CMV (cytomegalovirus) can cause a troublesome infection in the GI tract or elsewhere in the body. Symptoms include nausea, vomiting and diarrhea. CMV can cause ulcers and plaques in the GI tract. Ulcers in the colon can lead to profuse bloody diarrhea while ulcers in the upper GI tract (stomach, duodenum) often mimic peptic ulcer disease. CMV can also cause hepatitis.

Viral gastroenteritis includes the same "24-hour-bugs" and general maladies affecting everyone else. Unfortunately, transplant recipients are more prone to these pesky viruses because their immune systems are suppressed.

Viral gastroenteritis is generally not dangerous and tends to run a short, self-limiting course. Excess vomiting may be a problem if patients can't hold down their medications. If this is the case, hospitalization may be required to give intravenous fluids and medications.

Diabetes (high blood sugar levels) is the most common hormonal problem patients face post transplant and generally is the result of other medications taken, specifically Prograf and steroids.

Patients may require oral insulin or insulin injections. Severe and uncontrolled diabetes may require a change from tacrolimus to cyclosporin. As steroid dosages are reduced over time, the severity of the diabetes may lessen, along with the need for medication.

Testosterone levels may test low in males following transplantation but can be a pre-existing condition and associated with the underlying primary disease process.

Transplant recipients have lowered or suppressed immune systems, making them more susceptible to infection.

Here are some ways to protect yourself:

• Wash your hands frequently.
• Keep your hands away from your mouth and eyes.
• Stay away from people with colds and other infections.
• Avoid crowded enclosed areas for the first three months post transplant and after any treatment for rejection.
• Ask friends to visit only when they are well.
• Wash your hands after coughing and sneezing. Throw used tissues into the trash immediately.
• Do not eat or drink using the same glass or eating utensils used by anyone else.
• Ask family or friends who live with you to follow these same guidelines when they are sick.
• Avoid gardening or working in soil for six months after your transplant. Wear gloves once you resume gardening activities.
• Avoid handling animal waste and avoid contact with stray animals. Do not clean bird cages, fish or turtle tanks, or litter boxes. Cover your cat litter box.
• Avoid vaccines that consist of live viruses, such as Sabin oral polio, measles, mumps, German measles, yellow fever or smallpox. The live virus can cause infection. If you or any family member intends to receive vaccinations, notify your transplant team.
• Practice thorough oral hygiene every day. The mouth and teeth can be a source of infection. Regular brushing and flossing are essential, as are regular dental checkups.
• Avoid construction sites. Discuss in advance any possible home remodeling or construction projects with your physician or coordinator.
• Wear a mask when you come to the clinic. Park away from active construction sites.

Learn the warning signs of infection and report them to your transplant team immediately:

• Fever over 100 degrees F
• Flu symptoms including chills, aches, fatigue, headaches, dizziness, nausea and vomiting
• "Wet" productive cough and/or shortness of breath
• Nasal congestion with thick greenish or yellow drainage
• Sore throat
• Diarrhea
• Pain, burning during urination or feeling constant urge to urinate
• Any wound that is red or swollen with some drainage
• Mouth sores or thrush
• Rashes or skin lesions

Types of infection

Familiarize yourself with some of the different types of infections that can affect transplant patients. Notify your transplant team immediately if you suspect you have an infection.

Viral infections

• Cytomegalovirus (CMV) infects between 30% and 80% of all people (depending on where they live) at some point in their life. Like many viral infections, this virus is not dangerous to the public but can be serious in transplant recipients due to their weakened immune systems. Symptoms include fatigue, high fever, aching joints, headaches, nausea, vomiting, diarrhea, visual disturbances and pneumonia.
• Herpes zoster (shingles) is a recurrence of chicken pox appearing as a rash or as small water blisters on the chest, back or hip. Shingles may or may not be painful.

Fungal infections

• Candida can cause a variety of infections in transplant recipients. Most commonly it infects the mouth and throat, but also can be found in surgical wounds, eyes, respiratory and urinary tracts or the bloodstream. Candida that infects the mouth and throat is called thrush. Thrush produces white, patchy lesions, pain or tenderness, a white coating on the tongue and difficulty swallowing. You will take mycelex troches to prevent thrush. Candida that infects the vagina is more commonly known as a yeast infection and is identified by an abnormal white or yellow discharge from the vagina.
• Pneumocystis carinii is a fungal infection that causes a form of pneumonia called PCP. PCP can be prevented with Bactrim. If you are allergic to Bactrim, another medication will be substituted. Symptoms of PCP are shortness of breath, dry cough and fever.

Bacterial infections
Different types of bacteria can affect nearly any area of the body. Common bacterial infections include urinary tract infections, bronchitis, pneumonia, sinusitis, wound infections and blood infections. As with any potential infection, it is important you contact your transplant team immediately if you believe you have an infection.

The musculoskeletal system is especially vulnerable after transplantation. Extended hospital stays due to fractures or muscle weakness can lead to other problems such as limited mobility and pneumonia. We want to minimize as many of these problems as possible.

Osteoporosis is thinning of the bones. Osteoporosis can be a major problem post transplant and places patients at high risk for fractures and subsequent complications such as blood clots and pneumonia from lack of activity.

Patients often have osteoporosis prior to transplantation, especially those with chronic obstructive pulmonary disease (COPD), cystic fibrosis or a history of treatment with high doses of steroids. Compression fractures of the back are most commonly seen, but fractures of the arms, legs, or hips can occur.

Great care should be taken to prevent falls. All patients undergo bone density tests prior to transplant and receive aggressive treatment for both osteopenia (bone mass decrease) or osteoporosis (bone density loss). Calcium with Vitamn D supplements and bone mass restorative medications (such as Fosamax) are used routinely after transplant.

Muscle weakness is seen in the post-operative period and often results in prolonged hospitalization. Patients at highest risk include those who are seriously unfit, had limited mobility prior to transplant or received high doses of steroids.

Other medications such as cyclosporin and Prograf can affect the nervous system and perpetuate weakness. Muscle weakness often resolves slowly over time. The goal is to keep patients free of complications during this slow recovery period.

Transplant medications (cyclosporin or tacrolimus/FK506) are the major reason for neurological problems in recipients. Neurological side effects may be worsened by or accompany low magnesium levels, hypertension, low cholesterol, high-dose steroids or beta-lactam antibiotic therapy.

Minor neurological complications occur in about 20% of patients receiving tacrolimus and most commonly include hand tremors, sleep disturbances, headaches and mood changes. These side effects tend to be most pronounced soon after transplant.

Fortunately, more serious neurological complications are uncommon and occur in less than 5% of patients. These may include:

• Encephalopathy as a manifestation of a cerebrocerebellar syndrome resulting in seizures and cortical blindness
• Akinetic mutism, characterized by an apparent state of wakefulness, with no voluntary muscle activity
• A syndrome of unknown cause characterized by high ammonia levels in the blood that can result in severe neurological events or death

Hemorrhage (bleeding) can be a problem in the immediate post-transplant period. Bleeding usually occurs from the pleural space between the lungs and the inner chest wall. Patients who need to be placed on a heart-lung machine during their transplant are more predisposed to bleeding since their blood is thinned. Patients with excessive scarring in the pleural space from prior chest surgery, infection or placement of chest tubes are also predisposed to bleeding.

Post-transplant bleeding is usually easy to diagnose since all patients have chest tubes draining the pleural space. Some bleeding is a normal result of surgery, but heavy bleeding may require intervention. Depending on a patient's situation, he or she may receive blood products or coagulants to slow the bleeding. In some cases the patient must be returned to surgery to find the source of the bleeding.

Patients may also develop bleeding in their gastrointestinal tracts, a fairly common occurrence with any major surgery. Most patients receive medication prior to surgery to lessen the chance of GI bleeding.

Transplant recipients may experience kidney problems as a consequence of the anti-rejection and other medications they take. The cornerstones of current immunosuppressive regimens – cyclosporin and tacrolimus – can cause damage by constricting the arteries leading to the kidneys.

Most patients will have a "bump" in their serum creatinines while taking these drugs, indicating a decrease in renal function. Fortunately, most patients are able to function quite well despite this change in kidney function.

Drugs may be prescribed to counteract the negative effects of the immunosuppressive medications. Some of these include calcium channel blockers (e.g., diltiazem, nifedipine) to dilate blood vessels, pentoxyphylline, which improves the ability of red blood cells to pass through small blood vessels, and L-arginine.

Other drugs used post transplant that may affect kidney function include Bactrim, non-steroidal anti-inflammatories such as ibuprofen and toradol, antibiotics, ACE inhibitors and rapamycin.

Only a small percentage of patients – about 2% – will experience serious kidney problems that eventually could require dialysis or even kidney transplantation.

Other causes of kidney problems not unique to transplant recipients include dehydration and overuse of diuretics.