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American Journal of Critical Care. 2003;12: 497-507
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Pattern and Predictors of Early Rejection After Lung Transplantation

By Annette DeVito Dabbs, RN, PhD, Leslie A. Hoffman, RN, PhD, Aldo T. Iacono, MD, Chris L. Wells, PhD, PT, Wayne Grgurich, BS, Thomas G. Zullo, PhD, Kenneth R. McCurry, MD and James H. Dauber, MD. From Department of Acute and Tertiary Care, School of Nursing (ADD, LAH, CLW, TGZ), Division of Pulmonary, Allergy, and Critical Care Medicine (ATI, WG) and Division of Cardiothoracic Surgery (KRM), School of Medicine, University of Pittsburgh, Pittsburgh, Pa.


   Abstract
Top
 Abstract
Methods
 Results
 Frequency and Grade of...
 Discussion
 Study Limitations
 Nursing Implications
 Summary
 References
 
• Background Most lung transplant recipients experience improvement in their underlying pulmonary condition but are faced with the threat of allograft rejection, the primary determinant of long-term survival. Several studies examined predictors of rejection, but few focused on the early period after transplantation.

• Objectives To describe the pattern and predictors of early rejection during the first year after transplantation to guide the development of interventions to facilitate earlier detection and treatment of rejection.

• Methods Data for donor, recipient, and posttransplant variables were retrieved retrospectively for 250 recipients of single or double lung transplants.

• Results Most recipients (85%) had at least 1 episode of acute rejection; 33% had a single episode; 23% had recurrent rejection; 3% had persistent rejection; 13% had refractory rejection; and 14% had clinicopathological evidence of chronic rejection. Serious rejection (refractory acute rejection or chronic rejection) developed in 27% of recipients. Compared with other recipients, recipients who had serious rejection had more episodes of acute rejection (P = .004), and the first acute episodes occurred sooner after transplantation (P = .01) and were of a higher grade (P = .002).

• Conclusions Recipients who experienced higher grades for their first episode of acute rejection (P=.03) and higher cumulative rejection scores (P = .004) were significantly more likely than other recipients to have serious rejection during the first year after transplantation.

Lung transplantation is an established therapeutic option for some patients with end-stage pulmonary disease.1–4 Currently, survival rates after lung transplantation are reaching up to 73% for year 1 but gradually declining to 57% by year 3.5 The primary determinant of long-term survival is the development of chronic rejection,6,7 which is manifested histologically as obliterative bronchiolitis8 or clinically as bronchiolitis obliterans syndrome (BOS).9 The development of chronic rejection leads to progressive obstruction of airflow, causing lung transplant recipients to experience increased shortness of breath, reduced exercise tolerance, and diminished quality of life.10–12 Additionally, healthcare utilization, particularly rehospitalization and use of medications, is significantly higher for recipients who have rejection.13,14 Although transient improvement may occur after enhanced immunosuppression, treatment of chronic rejection is usually ineffective,15 and the eventual outcome is disability and death due to respiratory failure or infection.4

Rejection occurs more often, and has a greater propensity to recur, in recipients of lung allografts than in recipients of other transplanted organs.16,17 Although the exact pathogenesis of chronic rejection is unclear, the bulk of evidence supports uncontrolled acute rejection as the standard marker of risk for chronic rejection.6,18–22 Survival of lung transplant recipients is enhanced when acute rejection is detected early and appropriate treatments are implemented.6,23 However, the pathological process leading to rejection may be insidious, and signs and symptoms may not be apparent until the transplanted lung is severely compromised.24,25


Rejection occurs more often in lung allograft recipients than in any other transplant recipients.

 

Nurses are integral members of the transplant team, providing care before and immediately after the lung transplantation procedure, throughout the postoperative course, and during episodes of rejection that invariably develop. Little is known about the pattern of rejection and factors that may predict the development of rejection. Therefore, nurses are limited in their ability to anticipate which recipients are at greatest risk and to design interventions to reduce the occurrence of this complication. A better understanding of the pattern of rejection and associated factors may guide the development of interventions to facilitate earlier detection and treatment of rejection.

The purpose of this study was to describe the pattern of early rejection in lung transplant recipients and to identify characteristics of recipients in whom rejection develops, including factors that might be modified to decrease the prevalence of chronic rejection. Our aims were to describe the frequency and grade of episodes of acute rejection that occur during the first year after lung transplantation; describe the prevalence of recurrent, persistent, refractory, and chronic rejection; and identify factors that are predictors of serious rejection (refractory or chronic rejection).


   Methods
Top
 Abstract
 Methods
Results
 Frequency and Grade of...
 Discussion
 Study Limitations
 Nursing Implications
 Summary
 References
 
Sample
The retrospective sample for this study consisted of all recipients of initial single and double lung transplants (N = 250) performed by the University of Pittsburgh Medical Center transplant team between January 5, 1993, and September 12, 1998. Data for the variables of interest were retrieved retrospectively from the pulmonary transplant database. One transplant recipient was excluded because of incomplete data, yielding 249 subjects in the final sample.

Immunosuppressive Regimen
The immunosuppression protocol for the cohort included azathioprine (4 mg/kg) and methylprednisolone (5 mg/kg) immediately before the transplant procedure and either tacrolimus or cyclosporine given by continuous infusion postoperatively. None of the lung transplant recipients in this study received antibody induction therapy.

After transplantation, the maintenance primary immunosuppressive regimen consisted of prednisone (0.2 mg/kg per day) and either oral cyclosporine (6 mg/kg per day) or tacrolimus (0.3 mg/kg per day). Tacrolimus levels were maintained at approximately 10 to 15 ng/mL (determined by microparticle enzyme immunoassay of whole blood; IMx system, Abbott Laboratories, Abbott Park, Ill); cyclosporine levels, at 200 to 350 ng/mL (determined by monoclonal antibody fluorescence polarization immunoassay; TDx system, Abbott Laboratories).

During the study period, data from randomized clinical trials indicated that compared with use of cyclosporine, use of tacrolimus was associated with less frequent episodes of rejection,26 less persistent rejection,27 and significantly less obliterative bronchiolitis.28 Consequently, tacrolimus became the standard primary immunosuppressant.

Supplemental immunosuppression consisted of azathioprine (2 mg/kg per day) or mycophenolate mofetil (1 g twice per day). Azathioprine was the standard immunosuppressant because of its lower cost. The azathioprine dose was reduced if the leukocyte count decreased to less than acceptable levels. If recurrent rejection developed, lung transplant recipients were commonly switched to mycophenolate mofetil, which was much more costly than azathioprine. Maintenance corticosteroid usage was reduced with each biopsy that indicated no rejection to approximately 7.5 to 10 mg/d during the first year after transplantation.

If acute rejection (≥grade A2) or active obliterative bronchiolitis developed, immunosuppression was augmented with methylprednisolone (1.0 g/d for 3 days intravenously) or any of the following alternative treatments: prednisone (100 mg/d tapered to 10 mg/d during the course of 14 days), antithymocyte globulin (1.5 mg/kg per day for 5 days intramuscularly), Minnesota antilymphocyte globulin (20 mg/kg per day for 14 days intravenously), equine antilymphocyte globulin (15 mg/kg per day for 14 days intravenously), and polyclonal rabbit antithymocyte globulin (1.5 mg/kg per day for 7 days intramuscularly).

Assessment of Rejection
The presence of rejection in the lung allograft was assessed by using fiberoptic bronchoscopy according to a surveillance protocol. Transbronchial biopsies were performed routinely at 1 month after transplantation, then every 3 months during the first year after transplantation, and whenever rejection was clinically suspected. Biopsy specimens were examined by pathologists who graded the presence or absence of acute rejection by using standard nomenclature devised by the Lung Rejection Study Group29 (Table 1Go). The response to treatment for rejection was assessed within 6 weeks after treatment. An episode of acute rejection was defined by histological evidence of grade A2 or greater rejection, as classified by the Lung Rejection Study Group,8,29,30 with an interval of at least 6 weeks between biopsies to avoid counting multiple biopsy specimens positive for rejection that were actually due to the same occurrence of rejection. Biopsy results were retrieved for up to 2 weeks beyond the first year to verify continuation or resolution of a rejection episode. In addition, a cumulative rejection score was computed for each transplant recipient by summing the rejection grades for all acute episodes of grade A2 or greater that occurred during the year (eg, the cumulative rejection score would be 5 if a recipient had 1 episode of grade A2 rejection and 1 episode of grade A3 rejection). The presence of airway inflammation (grade B lesions) was determined on the basis of evidence of lymphocytic bronchitis/bronchiolitis in any biopsy specimen during the year as classified by the Lung Rejection Study Group.31


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  		Table 1 Grading of acute pulmonary allograft rejection29,30

 
Chronic rejection was defined by using the clinicopathological staging criteria for the diagnosis of BOS established by the International Society for Heart and Lung Transplantation.9 BOS scores of 0 (<20% decrease), 1 (20%–34% decrease), 2 (35%–49% decrease), or 3 (≥50% decrease) were assigned for unexplained declines in the forced expiratory volume in 1 second (FEV1) compared with the mean of 2 highest consecutive values after transplantation.9 BOS scores were designated "a" when the recipient had no histological evidence of obliterative bronchiolitis and "b" when the recipient had histological evidence of obliterative bronchiolitis. In order to further characterize the pattern of rejection, transplant recipients were assigned to mutually exclusive categories according to the worst level of rejection experienced at any time during the study period, and then the categories were combined into 2 groups (responsive and serious) to examine predictors of treatment response (Table 2Go).


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  		Table 2 Definitions for mutually exclusive categories of rejection

 
Selection of Potential Predictors of Rejection
Potential predictors were selected after a literature review to ascertain common modifiable and nonmodifiable characteristics thought to be associated with rejection in 4 categories: donor, recipient, donor-recipient match, and posttransplant complications (Table 3Go). Factors associated with potential injury to the allograft (eg, smoking histories, underlying disease, posttransplant complications) and factors that could prevent allograft injury (eg, use of immunosuppressive agents, preservation of pulmonary function) were included.


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  		Table 3 Possible predictors for the development of early rejection

 
Statistical Analysis
In order to assess the reliability of the database, 25 cases (10%) were randomly selected for verification with original source documents. Agreement between these documents (eg, pathology and laboratory reports) and database entries was 100%. Interrater reliability for coding the outcome variables was 96% between 2 independent raters.

Between-group differences for all potential predictive factors were determined by using {chi}2 analysis for categorical variables, an independent t test for continuous variables, and the Mann-Whitney U statistic for ordinal variables, with {alpha}set at .05. Computations were performed by using SPSS, Version 10 for Windows (SPSS Inc, Chicago, Ill). Logistic regression analysis for the development of serious rejection was performed by using only the factors that were significantly different between groups. Before the regression analyses were done, the factors were examined for multicollinearity; factors with multicollinearity were excluded from regression analysis to avoid compromising the analysis.


   Results
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 Abstract
 Methods
 Results
Frequency and Grade of...
 Discussion
 Study Limitations
 Nursing Implications
 Summary
 References
 
Sample
Table 4Go gives the general characteristics of the cohort. Overall survival at 1 year was 79% (196/249). Demographics, transplant procedures, and underlying diagnoses of recipients in the sample mirrored those of the population of lung and heart-lung recipients worldwide.5


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  		Table 4 Characteristics of the cohort (n = 249)*

 

Eighty-five percent of transplant recipients had at least 1 episode of acute rejection.

 

Results for 1206 transbronchial biopsies performed during the first year after transplantation were available; the mean was 5.09 (SD, 2.17; range, 1–12) biopsies per recipient. Data on the episodes of acute rejection were not available for 12 recipients who died before biopsies were performed. We found no statistically significant differences in age, sex, ethnic background, transplant procedure, or pretransplant diagnosis between these 12 recipients and the remaining cohort.


   Frequency and Grade of Acute Rejection Episodes
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 Methods
 Results
 Frequency and Grade of...
Discussion
 Study Limitations
 Nursing Implications
 Summary
 References
 
The mean number of episodes of acute rejection (≥grade A2) experienced per subject during the 1-year study period was 1.86 (SD, 1.48; range, 1–7; median, 1). The median onset of the first episode of acute rejection was day 20 (range, 3–359 days) after transplantation, and 75% of the f irst acute episodes occurred within the first 6 weeks after transplantation. The majority of first rejection episodes were grade A3 severity. Episodes of recurrent rejection were typically grade A2.

Figure 1Go presents the frequency of acute rejection episodes grade A2 or greater experienced in the first year. For example, 37 subjects (16%) had no (zero) episodes and 1 subject (0.4%) experienced 7 episodes. The cumulative rejection scores ranged from 0 to 22, with a mean of 4.7 (SD, 3.8) and a median of 4.0.



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  		Figure 1 Frequency of episodes of acute rejection ≥grade A2 during the first year after lung transplantation in 237 recipients.

 
Prevalence of Recurrent, Persistent, Refractory, and Chronic Rejection
Of the 237 recipients for whom we had biopsy data, 35 (15%) remained free of acute rejection, and 78 (33%) experienced only a single episode (Figure 2Go). However, 54 (23%) experienced recurrent acute rejection, 7 (3%) had persistent acute rejection, and 31 had (13%) refractory acute rejection. An additional 32 (14%) had clinicopathological evidence of chronic rejection during the first year. The onset of BOS ranged from 90 to 361 days after transplantation, with a median of 247 days. The 1-year mortality rate for recipients in the chronic rejection group was 9%: 1 death each on day 103 (respiratory failure associated with rejection), day 299 (cardiac failure associated with graft vascular disease), and day 318 (fungal infection).



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  		Figure 2 Distribution of cohort by categories of rejection. The responsive group consisted of the 174 patients who repsonded to treatment of graft rejection. The 63 patients in the serious group had refractory or chronic rejection.

 
Predictors of Serious Rejection
When the cohort was divided into 2 groups to examine differences between those who experienced serious rejection (n = 63; 31 refractory rejection and 32 chronic rejection) and those who responded to treatment (n = 174), significant between-group differences were found for the following factors (Table 5Go): number of rejection episodes (P = .004), grade of first rejection episode (P = .002), onset of first rejection episode (P = .01), primary immunosuppressant (tacrolimus vs cyclosporine; tacrolimus led to less acute rejection; P = .02), cumulative rejection score (P = .004), and evidence of lymphocytic bronchitis/bronchiolitis (P = .009). We found no significant between-group differences for any of the other factors listed in Table 3Go. Freedom from acute rejection is shown in Figure 3Go.


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  		Table 5 Significant predictors of serious rejection

 


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  		Figure 3 Freedom from acute rejection for patients who responded to treatment for graft rejection and patients who had serious (ie, refractory or chronic) rejection.

 
In order to examine whether any factors could be used to predict the development of serious rejection in the first year, variables with significant between-group differences were considered for logistic regression analysis (Table 6Go). The number of acute episodes was highly correlated with cumulative rejection scores (r = 0.732), and therefore this variable was not included in the regression analysis. Overall correct prediction when the remaining 5 variables were considered was 84.8% (responsive group 93.5% and serious group 65%). After the impact of the other variables was controlled for, recipients with higher grades for their first acute episode (P = .03) and higher cumulative rejection scores (P .004) were significantly more likely than other recipients to experience serious rejection. The remaining variables entered in the model, earlier onset of first episode (P = 0.41), cyclosporine as the primary immunosuppressant (P = .06), and presence of airway inflammation (grade B lesions; P = .75), were not significant predictors.


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  		Table 6 Regression analysis

 

   Discussion
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 Abstract
 Methods
 Results
 Frequency and Grade of...
 Discussion
Study Limitations
 Nursing Implications
 Summary
 References
 
The major findings of this study were as follows:

Our results support the proposed association between serious rejection and both acute rejection30 and airway inflammation31 in lung transplant recipients. Although grade B lesions were prevalent among recipients who experienced serious rejection and recipients who did not, only 1 recipient in the group with serious rejection had no evidence of airway inflammation (B lesions) during the first year. All recipients who had serious rejection soon after transplantation had episodes of acute rejection. Conversely, 26% of recipients who experienced recurrent rejection and 16% of those who experienced refractory rejection had episodes of serious rejection soon after transplantation. Our findings also indicate that recipients who had serious rejection had more frequent and more severe acute episodes, consistent with previous reports that the risk for chronic rejection is highest in the first 2 years after transplantation.6

Our findings also expand information on the pattern of rejection by revealing that lung transplant recipients who experienced an earlier onset of acute rejection and had a greater severity grade for the first acute episode were more likely than other recipients to have serious rejection within the first year after transplantation. Although none of the recipients in this study were treated with induction therapy, our findings support the use of intense induction and aggressive immunosuppression regimens in the early period after transplantation as a means of delaying the onset and severity of the first episode of acute rejection.32

Our results also indicate that obliterative bronchiolitis develops earlier (day 52 after transplantation) than previously reported in series that included lung transplant recipients who survived 60 days or more,6 90 days or more,20,21,30–34 or 1 year.35 Of the 32 recipients in our study who were categorized as having chronic rejection, 19 had evidence of obliterative bronchiolitis. However, the histological diagnosis of obliterative bronchiolitis was not always accompanied by decreases of 20% or more in FEV1. Of the 19 with evidence of obliterative bronchiolitis, 9 (47%) had BOS scores of 0b, supporting findings previously reported from our institution that suggest that a decrease of 12% or greater in FEV1 indicates a significant decrease in allograft function.36 In the 10 transplant recipients who met criteria for both obliterative bronchiolitis and BOS, histological evidence of obliterative bronchiolitis was detected in 4 before they had a decrease of 20% or more in FEV1. These findings reinforce the importance of performing surveillance bronchoscopy with transbronchial biopsy at periodic intervals to enhance the likelihood of earlier detection of chronic rejection.37 Because the sensitivity for diagnosing chronic rejection on the basis of histological criteria has been variable,38–42 spirometric criteria for staging BOS were also used to categorize chronic rejection. Using this strategy, we identified an additional 13 transplant recipients who had BOS scores of 1a or 2a and no histological evidence of obliterative bronchiolitis.

We also examined variations in immunosuppression. Primary immunosuppression consisted of (1) cyclosporine (20% of patients), tacrolimus (70% of patients), or a switch between the 2 agents (10% of patients) and (2) supplemental agents such as azathioprine or mycophenolate mofetil and prednisone. The reduction in the mean daily prednisone dose of 16 mg (SD, 6 mg) noted during the first 3 months after transplantation, compared with a mean of 11 mg (SD, 4 mg) during months 4 to 12, may have reflected the practice of slowly tapering off use of oral corticosteroids when graft rejection did not occur. Of the 6 recipients who did not receive prednisone during the year after transplantation because of contraindications for its use, 1 remained free of acute rejection, 3 experienced recurrent rejection, 1 had refractory rejection, and 1 had a BOS score of 3b.


Recipients with serious rejection had earlier, more severe, and more frequent acute rejection episodes that also included airway inflammation.

 

We also found that use of cyclosporine as the primary immunosuppressant was an early indicator for serious rejection within the first year after transplantation. This finding is consistent with the results of studies of lung transplant recipients treated with tacrolimus-based maintenance regimens,6 including prospective, randomized trials of tacrolimus versus cyclosporine, that indicated that the use of tacrolimus was associated with less acute and chronic rejection than was cyclosporine.26–28 More recent studies indicated that aerosolized cyclosporine may be an effective rescue therapy for patients with refractory acute rejection43,44 or chronic rejection.45 During our study interval, aerosolized cyclosporine was prescribed almost exclusively for transplant recipients who had serious rejection, and therefore use of aerosolized cyclosporine was not examined as a predictor. Triple-drug regimens (cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and prednisone) are routinely used as the maintenance immunosuppressants for lung transplant recipients27,43 but are not always successful, as indicated by the high prevalence of serious rejection in our study. The impact of early acute rejection on long-term survival reinforces the need to identify more effective therapies for acute rejection.

In addition to the association with acute rejection, cytomegalovirus (CMV) infection and pneumonitis have also been linked to the development of chronic rejection.4,20 Prophylaxis of transplant recipients at risk for CMV infection and preemptive treatment of recipients with CMV infection were used in some patients in our study, but no consensus exists on the most effective preventive approach.34 We also examined the influence of CMV serology mismatching (eg, donor seropositive for CMV and recipient seronegative for CMV) and CMV status (serum assays or cultures positive for CMV or illness due to CMV) after transplantation. Although other investigators have identified CMV disease as a risk factor for the long-term development of chronic rejection, neither the presence of CMV serology mismatching nor the development of evidence of CMV infection in lung transplant recipients was a significant predictor of serious rejection in the first year after transplantation.

Although previous investigators found that mismatches between donor and recipient in HLA antigens were a risk factor for early acute rejection6 and obliterative bronchiolitis,46 routine prospective HLA cross-matching is not done. Therefore, this factor was not analyzed as a possible predictor of serious rejection.

The response-to-injury hypothesis for the development of chronic rejection supports the need for strategies to prevent acute allograft injury.34 Sources of lung injury we examined that had not previously been studied as risk factors for rejection included the smoking history of both the donor and the recipient, matching of donor-recipient smoking histories, and evidence that the recipient smoked tobacco after transplantation or was exposed to tobacco smoke. Most lung transplant donors (51%) and candidates for lung donation (60%) had a history of smoking (mean, 7 pack-years; SD, 13 pack-years; range, up to 75 pack-years for donors and mean, 28 pack-years; SD, 30 pack-years; range, up to 135 pack-years for candidates). When the smoking histories of donors and recipients were matched, only 17% of the cohort had a history of no smoking for both the donor and the recipient. We attempted to document smoking and exposure to second-hand smoke among transplant recipients after transplantation, but insufficient data were available. However, evidence of kaolinate accumulation in macrophages (an indicator of recent tobacco use) obtained by bronchial alveolar lavage was detected in 124 (52%) of the 237 recipients for whom we had biopsy data. Although smoking was prevalent among the transplant recipients and donors, none of the smoking variables were predictive of serious rejection within the first year after transplantation.


   Study Limitations
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 Abstract
 Methods
 Results
 Frequency and Grade of...
 Discussion
 Study Limitations
Nursing Implications
 Summary
 References
 
This study was subject to the limitations associated with use of a retrospective database, including lack of control over study variables, data reliability, and missing data. Comparison between database entries and original source documents (pathology and laboratory reports) for a randomly selected sample of 10% of entries revealed no discrepancies, and only 1 recipient was excluded because of incomplete data entry, suggesting minimal or no error from database entries. An additional limitation is related to the study design. Although predictors were identified, we might have missed some relevant predictors. Further, causal relationships cannot be confirmed. However, study findings can establish whether predictor variables preceded the outcome of interest and were associated with the outcome variables. Accordingly, they can be used to direct future studies.


   Nursing Implications
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 Methods
 Results
 Frequency and Grade of...
 Discussion
 Study Limitations
 Nursing Implications
Summary
 References
 
When preparing new lung transplant recipients for discharge, nurses need to stress the importance of adhering to the daily immunosuppression regimen to reduce the body’s normal rejection response to the transplanted organ. Transplant recipients also should be informed that even though they are taking medications, they most likely will experience acute rejection. Only 15% of transplant recipients in our study escaped acute rejection during the first year after transplantation. Most episodes of acute rejection occurred within the first 6 weeks after transplantation, a time when transplant recipients are likely to be less knowledgeable about the signs and symptoms of rejection. Nurses should inform transplant recipients that if detected early, acute rejection usually responds to temporary augmentation of immunosuppression, such as a 3-day course of intravenous corticosteroids (1 g/d) or a "prednisone taper," which consists of an initial oral dose of 100 mg of prednisone followed by a gradual reduction in the daily dose over several weeks.


Because recipients often cannot identify signs and symptoms of rejection, increased nursing follow-up is recommended.

 

Because the prevalence of acute rejection is highest in the first few months after transplantation, nurses should instruct lung transplant recipients to immediately report any changes in the recipients’ condition, such as, but not limited to, fever, fatigue, or shortness of breath. Unfortunately, specific warning signs of acute rejection may not be apparent until the lung is severely compromised.16,37,39,46–48 Studies under way at our institution suggest that lung transplant recipients may be unable to distinguish signs and symptoms of acute rejection or may be reluctant to acknowledge this potential. Therefore, recipients may deny that they have signs or symptoms of rejection, or they may attribute the signs and symptoms to other problems, such as upper respiratory infections or fatigue.49 Increased contact with recipients through telephone calls can be used to more closely monitor patients’ status. Because signs and symptoms associated with rejection may develop insidiously and not be detected, nurses also should stress the importance of keeping appointments for follow-up evaluations, including transbronchial biopsy procedures. These follow-up visits also provide an opportunity to reinforce the importance of adherence to the medication regimen and the need for ongoing self-assessment to detect complications such as rejection.

Pulmonary function is an important clinical indicator of general lung allograft dysfunction.9 Therefore, lung transplant recipients should be taught to use a portable spirometer at home to measure forced vital capacity and FEV1.50,51 Home spirometry allows recipients to monitor trends in their pulmonary function over time, including periods when signs and symptoms of rejection may be too subtle to recognize.52,53 Patients should be instructed to use the spirometer daily and to notify the transplant team of decreases of 10% or greater in forced vital capacity or FEV1, which may indicate the development of rejection and warrant further evaluation.54


   Summary
Top
 Abstract
 Methods
 Results
 Frequency and Grade of...
 Discussion
 Study Limitations
 Nursing Implications
 Summary
References
 
Our findings confirm that the severity and onset of the first episode of acute graft rejection, as well as the frequency and severity of episodes of recurrent rejection throughout the first year after lung transplantation, are significant predictors of the development of early serious rejection. Because of these findings, nursing interventions should focus on teaching and reinforcing ways to prevent episodes of early rejection, reduce the severity of the episodes, and ensure prompt recognition of the signs and symptoms of rejection.


   ACKNOWLEDGMENTS
 
We acknowledge David Plaskon for assistance in determining the BOS scores. This research was supported by Mallinckrodt Inc-American Association of Critical-Care Nurses and grant F31 NR07425 from the National Institute of Nursing Research, National Institutes of Health, US Public Health Service.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


   REFERENCES
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