This appendix integrates the UTH Manual 2022 standard protocols with clinical practice experience, providing a comprehensive timeline from referral through long-term follow-up for lung transplant patients.
⚠️ Marker = Requires clinical team confirmation based on TSGH institutional protocols 📋 Marker = TSGH institutional data to be supplemented
D.1 Pre-Transplant Evaluation Period
D.1.1 Referral and Initial Outpatient Assessment
| Referral intake |
Referred from pulmonology/thoracic surgery or external hospital |
Day 0 |
| Initial clinic evaluation |
mMRC dyspnea assessment, basic PFT, 6MWT, CXR |
First clinic visit |
| Medical record summary |
Prepare PowerPoint summary (including CXR, CT, cardiac catheterization images) [UTH-Manual-2022] |
Within 1 week of initial evaluation |
D.1.2 Comprehensive Evaluation (3-5 Day Admission)
Per UTH Manual registry system, comprehensive evaluation items [UTH-Manual-2022]:
Day 1 - Chest X-ray, chest CT - Complete pulmonary function testing (FEV1, FVC, DLCO, TLC) - Arterial blood gas analysis (A-aDO2 calculation) - Basic blood tests
Day 2 - mMRC scoring - 6-minute walk test (6MWT) - Echocardiography - ⚠️ Right heart catheterization (if mPAP > 35 mmHg)
Day 3 - HLA typing - PRA (Panel Reactive Antibody) testing - CMV/EBV serology - Infectious disease screening (HIV, HTLV-1, HBs, HCV)
Day 4-5 - Multidisciplinary consultations (dental, psychiatry, rehabilitation, nutrition, social work) - Vaccination assessment and catch-up (measles, rubella, varicella, mumps, etc.) [UTH-Manual-2022] - If needed: coronary angiography (CAG)
D.1.3 Indication Review Meeting
| Institutional MDT discussion |
Thoracic surgery, pulmonology, anesthesia, ICU, infectious disease |
1-2 weeks after evaluation completion |
| ⚠️ Central Indication Review Committee |
Submit application, await review result (approved/not approved/conditional) |
After institutional approval |
| Result notification |
Written notification to patient and family |
After committee review |
D.1.4 Waitlist Registration
| JOT registration ⚠️ |
Japan uses JOT system; TSGH follows MOHW Organ Donation and Transplant Registry Center procedures |
| Documents at registration |
Complete evaluation data, HLA typing, PRA, CMV status, weight/height (for size matching) |
| Status classification |
Based on disease severity (⚠️ Taiwan classification system to be confirmed) |
D.2 Waitlist Period Management
D.2.1 Periodic Follow-Up Schedule
| Every 1-2 months |
Clinic visit: mMRC, weight, SpO2, oxygen requirement changes |
| Every 3 months |
PFT follow-up (FVC, FEV1 trends) |
| Every 6 months |
Chest CT, complete blood work, HLA antibody tracking |
| Annually |
Right heart catheterization (if PAH concern), 6MWT, vaccine update |
D.2.2 Waitlist Clinical Key Points
Based on clinical practice observations [UTH-Manual-2022]:
- Weight monitoring: Weight loss during waitlist period is common; close nutritional status tracking required
- Oxygen requirement trending: Record resting and exertional oxygen flow rate changes
- ADL assessment: Walking distance, self-care ability, wheelchair dependency
- Status upgrade evaluation: When condition worsens, reassess and apply for status change with registry center
D.2.3 Transplant Coordinator Visits
Per clinical practice, coordinator periodic visit content includes [UTH-Manual-2022]:
| Disease tracking |
Respiratory symptoms, oxygen use, weight changes, ADL |
| Registry blood sample update |
Periodically update blood specimens required by registry center |
| Psychological assessment |
Waitlist anxiety, end-of-life wishes confirmation |
| Family situation |
Caregiver support, housing arrangements, financial status |
| Education |
Surgical preparation, postoperative expectations, rehabilitation outlook |
| Prehabilitation |
Confirm rehabilitation exercise compliance (walking, breathing exercises) |
D.2.4 Prehabilitation Protocol
| Aerobic exercise |
Daily walking (adjusted per tolerance) or walking machine 30 min/day |
| Strength training |
Lower extremity strength (squats, etc.), respiratory muscle training |
| Nutritional support |
High-protein, high-calorie diet; ⚠️ nutritional supplements (e.g., PulmoCare) |
| Visiting rehabilitation |
1-2x/week visiting rehabilitation therapist (pulmonary rehab + bed-level strength training) |
D.3 Organ Offer Notification to Admission
D.3.1 Notification Process (Hourly)
Hour 0 Organ donation center notification → Transplant coordinator receives notification
├─ Confirm donor information (ABO, size match, CMV status, HLA)
├─ Evaluate size matching (VCD/VCR ±30% adult; ±12% pediatric) [UTH-Manual-2022]
└─ Notify lead surgeon, decide whether to accept
Hour 0-1 Notify recipient for admission
├─ Coordinator contacts patient/family
├─ Confirm transportation method and estimated arrival time
└─ Activate surgical team call-in
Hour 1-3 Recipient arrives at hospital
├─ Emergency department or direct ward admission
├─ Pre-op blood work (CBC, chemistry, coagulation, Type & Screen, ABG)
├─ Chest X-ray
├─ COVID-19 PCR ⚠️
├─ Crossmatch specimen sent
└─ Anesthesia pre-op evaluation
Hour 2-4 Pre-op preparation
├─ Surgical consent signing
├─ Anesthesia consent signing
├─ ⚠️ Pre-op immunosuppressant administration:
│ ├─ MMF (CellCept) 500 mg PO [UTH-Manual-2022]
│ └─ Methylprednisolone (Solu-Medrol) 500 mg IV
├─ Pre-op antibiotics (PIP/TAZ 4.5g)
└─ Transfer to operating room
D.3.2 Family Arrangements
| Family waiting area |
Arrange family in surgical waiting area |
| Contact person |
Coordinator or nurse provides periodic surgical progress updates |
| Accommodation |
Assist with in-hospital or nearby accommodation for families traveling from afar ⚠️ |
D.4 Surgery Day (Day 0)
D.4.1 Anesthesia Preparation Sequence
Per UTH Manual and clinical practice [UTH-Manual-2022]:
| T-60 min |
Patient enters OR, identity and surgical site verification |
| T-45 min |
Arterial line (A-line) placement |
| T-30 min |
General anesthesia induction (Propofol, Fentanyl, muscle relaxant) |
| T-20 min |
Double-lumen endotracheal tube or bronchial blocker insertion |
| T-15 min |
Central venous catheter (CV line) — right internal jugular vein |
| T-10 min |
Swan-Ganz pulmonary artery catheter insertion |
| T-5 min |
Transesophageal echocardiography (TEE) placement |
| T-0 |
Prep and drape complete, ready to operate |
D.4.2 Surgical Steps and Time Estimates
Typical BLTx (bilateral lung transplant) surgical workflow, per clinical practice data:
≈ Hour 0 Clamshell incision (4th intercostal bilateral thoracotomy)
Pericardial inverted-T incision
≈ Hour 0.5 Central ECMO cannulation
├─ SVC: drainage cannula (e.g., 20Fr)
├─ IVC: drainage cannula (e.g., 20Fr)
└─ Ascending aorta: return cannula (e.g., 15Fr)
Confirm full flow
≈ Hour 1-2 First side pneumonectomy (usually right lung)
├─ Hilum dissection
├─ Pulmonary artery stapling
├─ Pulmonary vein stapling
└─ Bronchus stapling
≈ Hour 2-3 First side donor lung implantation
├─ Bronchial anastomosis (4-0 PDS)
├─ Pulmonary artery anastomosis (5-0 Pronova)
└─ Left atrial anastomosis (4-0 Pronova)
→ Reperfusion
≈ Hour 3-5 Second side pneumonectomy + donor lung implantation (same steps)
→ Reperfusion
≈ Hour 5-6 ECMO weaning
├─ Gradual ECMO flow reduction
├─ Monitor mPAP, BP, SpO2
├─ Initiate iNO (10-20 ppm) if needed [UTH-Manual-2022]
├─ Bronchoscopic suctioning
└─ Confirm hemodynamic stability before ECMO decannulation
≈ Hour 6-7 Chest closure
├─ Place chest drains (4 tubes)
├─ Pericardial reconstruction (Gore-Tex sheet)
├─ Sternal wire fixation
└─ Layered closure
≈ Hour 7-8 Post-operative bronchoscopy
Confirm anastomotic patency, no reperfusion injury
≈ Hour 8+ Transfer to ICU
Typical Time Parameters [per clinical practice]:
| Total surgical time |
8-10 hours |
| Cold ischemic time (CIT) |
First lung 4-6 hr; second lung 6-8 hr |
| Warm ischemic time (WIT) |
45-70 min/side |
| Total ischemic time |
6-8 hr (first lung); 7-9 hr (second lung) |
D.4.3 Intraoperative Immunosuppression
| Pre-op (before anesthesia induction) |
MMF (CellCept) |
500 mg PO |
| Intraoperative (before reperfusion) |
Solu-Medrol |
500 mg IV (some centers use 500-1000 mg) |
D.4.4 Intraoperative ECMO Management Points [UTH-Manual-2022]
- Central V-A ECMO is the standard configuration
- iPAH patients: Post-op ICU ECMO maintenance for 2-3 days before weaning attempt
- ECMO weaning failure: Restore flow, troubleshoot cause (PH, bleeding, airway secretions) before re-attempting
- iNO 20 ppm can assist ECMO weaning
D.5 ICU Care Timeline (POD 0-14)
D.5.1 POD 0 (Surgery Day, ICU Admission)
| Ventilator settings |
Lung protective: Vt 6-8 mL/kg, PEEP 5 cmH2O, plateau < 30 cmH2O [UTH-Manual-2022] |
| iNO |
If used intraoperatively, maintain 10-20 ppm, gradually wean after 12-24 hours [UTH-Manual-2022] |
| Hemodynamics |
Swan-Ganz monitoring mPAP, CVP, CO/CI, SvO2 |
| Fluids |
Restrictive fluid strategy, 30-40 mL/kg/day [UTH-Manual-2022] |
| Targets |
SvO2 ≥ 60%, CI ≥ 2.5 |
| Drug initiation |
Tacrolimus IV continuous infusion (see D.6) |
| Antibiotics |
PIP/TAZ 4.5g q8h [UTH-Manual-2022] |
| Antifungal |
Micafungin 100 mg/day IV (200 mg on ECMO) [UTH-Manual-2022] |
| Antiviral |
Ganciclovir 5 mg/kg/day IV [UTH-Manual-2022] |
| ABG |
Immediately upon admission, then q4-6h |
| CXR |
Immediately upon admission (baseline) |
| Labs |
CBC, chemistry, coagulation (on admission) |
D.5.2 POD 1
| Immunosuppression |
mPSL 250 mg IV x 1 [UTH-Manual-2022] |
| Tacrolimus monitoring |
1st trough level (6 hours after initiation) [UTH-Manual-2022] |
| 2nd Tac level |
16 hours after initiation |
| Basiliximab |
POD 1: Simulect 20 mg + NS 50 mL (30-minute infusion) (if used) [UTH-Manual-2022] |
| IVIg |
POD 1-2: Venoglobulin 7.5 g (if used) [UTH-Manual-2022] |
| CellCept |
Start PO/NG: BW < 50 kg → 500 mg/day; BW ≥ 50 kg → 1000 mg/day (divided BID) [UTH-Manual-2022] |
| CXR |
Daily |
| Bronchoscopy |
As needed (check anastomosis, suction) |
D.5.3 POD 1-3: High-Dose mPSL Phase
| POD 1 |
250 mg IV x 1 |
First Tac level, CellCept started |
| POD 2 |
250 mg IV x 1 |
Continue ventilator management, begin extubation readiness assessment |
| POD 3 |
250 mg IV x 1 |
Chest drain output evaluation, begin enteral nutrition assessment |
D.5.4 POD 4-6: mPSL Taper Phase
| POD 4 |
125 mg IV x 1 |
Basiliximab 2nd dose (POD 4) [UTH-Manual-2022] |
| POD 5 |
125 mg IV x 1 |
Extubation assessment (target within 72 hours) |
| POD 6 |
125 mg IV x 1 |
Post-extubation oral medication transition preparation |
D.5.5 POD 7-9: Final mPSL Taper
| POD 7 |
62.5 mg IV x 1 |
Begin Tacrolimus IV → oral conversion [UTH-Manual-2022] |
| POD 8 |
62.5 mg IV x 1 |
Track Tac oral trough level |
| POD 9 |
62.5 mg IV x 1 |
Switch antifungal to ITCZ oral (20 mL suspension) |
D.5.6 POD 10-14: Stabilization Phase
| POD 10 |
Prednisolone 30 mg PO begins (replaces IV mPSL) [UTH-Manual-2022] |
| POD 10 |
Tacrolimus IV → oral conversion complete |
| POD 10-14 |
PSL taper 2.5 mg/week → target 5 mg/day maintenance [UTH-Manual-2022] |
| POD 10-14 |
Valganciclovir 900 mg/day PO replaces GCV IV [UTH-Manual-2022] |
| POD 14 |
Baktar (TMP-SMX) starts (1 tab x 1/day, Mon-Wed-Fri) [UTH-Manual-2022] |
D.5.7 Ventilator Weaning and Extubation Timeline
| POD 1-2 |
Begin weaning trial (reduce PEEP, reduce PS) |
| POD 2-3 (target 72 hours) |
Extubation [UTH-Manual-2022] |
| Post-extubation |
HFNC or NIV transition |
| Extubation delay > 7-14 days |
Evaluate tracheostomy [UTH-Manual-2022] |
D.5.8 Nutritional Support Timeline [UTH-Manual-2022]
| POD 0 |
TPN initiated (Elneopa, etc.) |
| POD 1-2 |
Tube feeding starts: 50 mL/hr Glutamine F, gradually increase |
| POD 2-3 |
Switch to PulmoCare tube feeding |
| Post-extubation |
Oral diet begins (liquids → soft → regular diet) |
| Target |
Harris-Benedict BEE x 1.2-1.8; protein 1.2-2.0 g/kg/day |
D.5.9 Rehabilitation Initiation Timeline
| POD 1-2 |
Bed-level passive exercises, ROM |
| POD 2-3 |
Bedside sitting |
| POD 3-5 |
Wheelchair transfer (even with multiple lines) |
| Post-extubation |
Standing, walking training |
| POD 7-14 |
Progressive daily walking distance increase |
D.5.10 Bronchoscopy Schedule
| Immediately post-op (in OR) |
Confirm anastomotic patency, assess reperfusion injury |
| POD 1-3 |
Suctioning, anastomotic healing assessment |
| POD 7 (Week 1) |
Protocol biopsy + BAL |
| POD 14 (Week 2) |
Anastomosis follow-up, rejection assessment |
| ⚠️ Thereafter per center protocol |
Every 1-2 weeks until discharge |
D.6 Immunosuppression Timeline
D.6.1 Overview Flowchart
Pre-op ─────────── Intra-op ──── POD 0 ── POD 1 ── POD 4 ── POD 7-10 ── POD 10 ── Post-discharge
MMF 500mg PO ──────────── → CellCept 500-1500mg/day PO continuous ──────────→
Solu-Medrol ──── 500mg IV
mPSL 250mg×3d → 125mg×3d → 62.5mg×3d
PSL 30mg PO → taper to 5mg
Tac IV 0.03mL/kg/hr ──────────→ Tac oral
(×1.5-2 IV rate)
Basiliximab ── D1 ──── D4
D.6.2 Tacrolimus Detailed Timeline [UTH-Manual-2022]
| POD 0 (ICU admission) |
Prograf 1A (2mg/0.4mL) + NS 50mL IV drip |
0.03 mL/kg/hr |
|
|
BW 30kg → 0.9 mL/hr |
|
|
BW 50kg → 1.5 mL/hr |
|
|
BW 70kg → 2.1 mL/hr |
| POD 1 (6hr) |
1st trough level blood draw |
Target 15-20 ng/mL |
| POD 1 (16hr) |
2nd trough level blood draw |
|
| Thereafter |
Daily trough level (ICU: draw from A-line) |
|
| POD 7-10 |
IV → Oral conversion |
Oral dose = IV rate x 1.5-2 |
|
|
Example: IV 0.8 mL/hr → oral 1.2-1.6 mg q12h |
|
⚠️ With concurrent ITCZ or VRCZ |
Oral dose = IV rate x 1.0 |
Tacrolimus Target Levels [UTH-Manual-2022]:
| 0-3 months |
14-17 |
| 3-6 months |
10-15 |
| > 6 months |
8-12 |
D.6.3 Corticosteroid Detailed Timeline [UTH-Manual-2022]
| Intraoperative (before reperfusion) |
Solu-Medrol |
500 mg |
IV bolus |
| POD 1-3 |
mPSL |
250 mg/day |
IV x 1/day |
| POD 4-6 |
mPSL |
125 mg/day |
IV x 1/day |
| POD 7-9 |
mPSL |
62.5 mg/day |
IV x 1/day |
| ⚠️ Alternative |
mPSL |
62.5 → 40 → 30 mg (stepwise) |
Some centers use 3-day steps |
| POD 10 |
Prednisolone (PSL) |
30 mg |
PO |
| From POD 10 |
PSL taper |
2.5 mg/week reduction |
PO |
| Maintenance dose |
PSL |
5 mg/day |
PO, long-term |
Weight-Based Prednisone Reference Dosing [UTH-Manual-2022]:
| 3 months |
0.25 mg/kg/day |
15 mg |
10 mg |
| 6 months |
0.15 mg/kg/day |
9 mg |
6 mg |
| 9 months |
0.08-0.1 mg/kg/day |
5-6 mg |
3-4 mg |
D.6.4 Basiliximab (Simulect) [UTH-Manual-2022]
- Indication: When Tacrolimus initiation is delayed or renal function is poor
- POD 1: Simulect 20 mg + NS 50 mL, infuse over 30 minutes or more
- POD 4: Simulect 20 mg + NS 50 mL, infuse over 30 minutes or more
D.6.5 MMF (CellCept) [UTH-Manual-2022]
| Pre-op |
500 mg PO |
9 hours before surgery (first dose) |
| POD 0 (21:00) |
CellCept 500 mg |
NG/PO |
| POD 1 onward |
BW < 50 kg: 500 mg/day; BW ≥ 50 kg: 1000 mg/day |
Divided BID (7:00, 19:00) |
| During rejection |
May increase to 3000 mg/day (ACR) or ≥ 1500 mg/day |
|
| Side effect monitoring |
Reduce or hold when WBC < 1500/uL |
|
D.6.6 Alternative: Cyclosporine (Neoral) [UTH-Manual-2022]
| Indication |
When Tacrolimus is not tolerated |
| Starting dose |
5 mg/kg PO divided BID |
| Trough target |
0-3m: 250-350; 3-6m: 200-300; >6m: 150-250 ng/mL |
D.7 Infection Prevention Timeline
D.7.1 Perioperative Antibiotics [UTH-Manual-2022]
| Pre-op |
PIP/TAZ |
4.5g IV |
30 minutes before incision |
| POD 0 onward |
PIP/TAZ |
4.5g q8h IV |
Continue at least 7-14 days; adjust per donor culture results |
| Donor MRSA |
Add Vancomycin |
1g q12h |
|
| Donor Pseudomonas |
Switch to Ceftazidime or Meropenem |
|
|
| ESBL positive |
Meropenem |
1g q8h |
|
D.7.2 Antifungal Prophylaxis [UTH-Manual-2022]
| ICU (from POD 1) |
Micafungin (MCFG) |
100 mg/day IV (200 mg on ECMO) |
Until ECMO decannulation + ICU discharge |
| Oral transition |
Itraconazole (ITCZ) suspension |
20 mL/day |
May switch to capsules after 7 days or more |
| Maintenance |
ITCZ capsule |
50-200 mg/day |
At least 3-6 months |
| Inhaled |
Amphotericin B (Fungizone) nebulized |
|
Starting in ICU, ⚠️ per center protocol |
D.7.3 CMV Prevention [UTH-Manual-2022]
| D+/R- (highest risk) |
Prophylaxis |
GCV IV 5 mg/kg/day → VGC PO 900 mg/day |
Start immediately post-op |
12 months or more (0-6m: 900 mg → 6-12m: 450-900 mg) |
| D+/R+ or D-/R+ |
Prophylaxis |
VGC PO 900 mg/day |
Start when oral intake possible |
6 months |
| D-/R- |
Low risk |
Acyclovir PO 400 mg x 2/day |
|
6 months |
CMV Monitoring Schedule: - ICU period: C7-HRP or CMV-PCR 1-2x/week - First 3 months post-discharge: Every 1-2 weeks - 3-12 months: Monthly - Preemptive therapy threshold: C7-HRP ≥ 10/50,000; CMV-PCR ≥ 1500 IU/mL (R+) or ≥ 500 IU/mL (R-) [UTH-Manual-2022]
D.7.4 PCP Prevention [UTH-Manual-2022]
| TMP-SMX (Baktar/Bactrim) |
1 tab/day, Mon-Wed-Fri |
POD 14 (or when oral intake possible) |
Lifelong |
| Alternative (TMP-SMX allergy) |
Atovaquone (Samitrel) 1500 mg/day |
|
Lifelong |
D.7.5 Inhaled Medication Schedule [UTH-Manual-2022]
| Meptin (Procaterol) nebulized |
q4h → PRN |
Start immediately upon ICU admission |
Bronchodilator |
| Atrovent (Ipratropium) nebulized |
q4h |
ICU admission |
|
| QVAR (Beclomethasone) inhaled |
2 puffs BID-QID |
When oral intake possible |
Local anti-inflammatory |
| Tobramycin nebulized |
PRN |
When Pseudomonas culture positive |
180-270 mg |
| Amphotericin B nebulized |
PRN |
When Aspergillus risk present |
25 mg |
D.8 Discharge Preparation and Criteria
D.8.1 Discharge Criteria Checklist
| Respiratory |
Weaned from ventilator, stable on room air or low-flow O2 |
| Pulmonary function |
FEV1 stable or improving |
| CXR |
Stable, no new infiltrates |
| Immunosuppression |
Stable oral triple therapy (Tac + MMF + PSL), Tac level on target |
| Infection |
No active infection |
| Nutrition |
Adequate oral intake |
| Mobility |
Independent walking or minimal assistance |
| Wound |
Healing well |
| Rejection |
Bronchoscopy biopsy with no significant rejection (≤ A1) |
| Education |
Completed education (see below) |
D.8.2 Discharge Education Items
| Medication guidance |
Triple IS timing (morning 8:30 take Prograf/CellCept/Prednisone) [UTH-Manual-2022] |
|
Anti-infective drugs (ITCZ, Baktar, VGC) |
|
GI protective drugs (PPI, Metoclopramide, etc.) |
| Self-monitoring |
Daily temperature, weight, SpO2 |
|
Home spirometer (HiChek, etc.) use [UTH-Manual-2022] |
| Infection prevention |
Hand hygiene, oral hygiene (brush after every meal) |
|
Avoid crowded places, wear mask |
|
Food safety (avoid raw foods) |
| Follow-up |
Inform follow-up frequency (see D.9) |
| Emergency contacts |
Provide 24-hour contact number, when to seek emergency care |
D.8.3 Sample Discharge Medication List [UTH-Manual-2022]
| Immunosuppression |
Tacrolimus (Prograf) |
Per trough adjustment |
|
MMF (CellCept) |
500-1500 mg/day divided BID |
|
Prednisolone |
Tapering (target 5 mg/day) |
| Antifungal |
ITCZ suspension/capsule |
20 mL/day or 50-200 mg |
| Antiviral |
Valganciclovir (Valixa) |
Per CMV risk 450-900 mg |
| PCP prevention |
TMP-SMX (Baktar) |
1 tab Mon-Wed-Fri |
| Inhaled |
QVAR + Procaterol |
BID-QID |
| GI |
Metoclopramide 15 mg, Pantoprazole |
|
|
Lubiprostone (Amitiza) 48 ug or Senokot |
Constipation prevention |
| Probiotic |
Miyairi-BM or Biofermin-R |
1 g |
| Sleep aid |
Ramelteon (Rozerem) 8 mg |
PRN |
| Bone health |
Alendronate 35 mg Monday, Vit D3 |
See D.10 |
D.9 Post-Discharge Follow-Up Schedule
D.9.1 Clinic Visit Frequency [UTH-Manual-2022]
| Post-discharge weeks 1-4 |
1-2 times/week |
Basic labs + Tac level + CXR |
| Months 1-3 |
Every 1-2 weeks |
Labs + Tac level + PFT + CXR |
| Months 3-6 |
Every 2 weeks to monthly |
Labs + Tac level + PFT |
| Months 6-12 |
Monthly |
Labs + Tac level + CT (every 3-6 months) |
| > 12 months |
Every 2-3 months |
Annual comprehensive workup |
D.9.2 Tests at Each Visit [UTH-Manual-2022]
Basic items (every visit): - CBC, chemistry (liver/renal function) - Tacrolimus (or CsA) trough level - CXR - Home spirometer data review
Periodic additional items:
| Every 1-2 weeks (first 3 months) |
CMV (C7-HRP), EBV-DNA, Aspergillus antigen |
| Monthly (3-12 months) |
CMV monitoring, IgG/IgA/IgM |
| Every 3-6 months |
Chest CT, HLA antibody (DSA) tracking |
| Every visit |
Aspergillus antigen, Candida antigen, beta-D-glucan |
D.9.3 Protocol Bronchoscopy Schedule
| POD 7 |
1st protocol biopsy + BAL |
| POD 14 |
2nd biopsy |
| 1 month |
Surveillance biopsy |
| 3 months |
Surveillance biopsy |
| 6 months |
Surveillance biopsy |
| 12 months |
Surveillance biopsy |
| ⚠️ Thereafter |
Per clinical need (add when FEV1 decline > 10%) |
Each BAL submission: - Bacterial culture (including Aspergillus, Cryptococcus, Mucor, Nocardia) - Acid-fast stain/culture (TB/NTM) - CMV PCR - Cytology
D.10 Long-Term Milestones
D.10.1 Timeline Overview
| 3 months |
Tac level target lowered to 10-15 ng/mL |
|
mPSL taper target: 0.25 mg/kg/day |
|
First bone density scan (DEXA) [UTH-Manual-2022] |
|
Evaluate need for mTOR inhibitor |
|
Consider vaccination (inactivated vaccines) |
| 6 months |
Tac level target lowered to 8-12 ng/mL |
|
mPSL taper target: 0.15 mg/kg/day |
|
First annual comprehensive laboratory panel |
|
CMV prophylaxis evaluation (D+/R+ or D-/R+ may consider discontinuation) |
|
Antifungal evaluation (may consider stopping ITCZ) |
| 9 months |
mPSL target: 0.08-0.1 mg/kg/day (5-6 mg) |
| 12 months |
Annual comprehensive examination |
|
Chest CT, complete PFT, 6MWT |
|
HLA antibody (DSA), bone density follow-up |
|
Lipids, glucose, HbA1c |
|
Cancer screening (dermatology, cervical smear, etc.) |
|
CMV/EBV monitoring |
| Annually (> 1 year) |
Annual comprehensive workup (same as above) |
|
DEXA, vaccine assessment update |
|
CLAD screening (FEV1 trend analysis) |
|
PTLD monitoring (EBV-DNA), skin cancer screening |
D.10.2 Osteoporosis Prevention and Treatment [UTH-Manual-2022]
| Screening |
Treat when YAM < 80% or T-score ≤ -2.5 SD |
| First-line |
Alendronate 35 mg PO weekly |
| Vitamin D |
Eldecalcitol 0.75 ug/day or Alfacalcidol 1.0 ug/day |
| Second-line |
Denosumab (Pralia) 60 mg SC every 6 months |
| Follow-up |
DEXA annually; fracture risk assessment |
D.10.4 CLAD Monitoring [UTH-Manual-2022]
| FEV1 decline > 10% |
Possible CLAD |
Follow-up confirmation |
| FEV1 decline > 20% sustained > 3 weeks |
Probable → Definite CLAD |
Bronchoscopy + CT + HLA antibodies |
| TLC decline > 10% |
Suspect RAS |
Add CT to differentiate BOS vs RAS |
CLAD Treatment Options [UTH-Manual-2022]: 1. Azithromycin 250 mg QOD 2. Montelukast 10 mg/day 3. Pulse steroid (mPSL 500 → 250 → 125 mg x 3 days) 4. Thymoglobulin 1.5 mg/kg (severe cases)
D.11 Special Population Considerations
D.11.1 iPAH (Idiopathic Pulmonary Arterial Hypertension) Patients [UTH-Manual-2022]
- Post-op ECMO maintenance for 2-3 days, do not rush to wean
- PEEP management requires more conservative approach
- Vasopressor priority: Catecholamine → Milrinone → Prostacyclin (PGE1 0.01-0.02 ug/kg/min)
- May require OnO/Octanoate 1-2 ug/kg/min
D.11.2 Pediatric Patients
- Size matching criteria: predicted VC difference ±12% (pediatric-specific formula) [UTH-Manual-2022]
- Central ECMO cannulation technical details require adjustment (smaller caliber)
- Nutritional support: Consider pediatric-specific formulas
- Psychological support: Multidisciplinary team (child life specialist, psychologist, social worker)
- Family accommodation and care arrangements
D.11.3 Retransplantation Patients [UTH-Manual-2022]
- Higher surgical difficulty (severe adhesions)
- CLAD is the most common indication
- Higher postoperative bleeding risk
- Immunosuppression may require adjustment (already sensitized)
D.12 Emergency Situation Timeline
D.12.1 When to Seek Emergency Care
| Fever > 38 degrees C |
Infection, rejection |
Seek immediate care |
| SpO2 decline > 3-5% from baseline |
PGD, rejection, infection |
Seek immediate care |
| FEV1 decline > 10% |
Rejection, CLAD, infection |
Seek care within 24 hours |
| Acute worsening dyspnea |
Multiple causes |
Seek immediate care |
| Hemoptysis |
Anastomotic problems, infection |
Seek immediate care |
References [UTH-Manual-2022] University of Tokyo Hospital Department of Thoracic Surgery, Lung Transplant Handbook 2022 Edition (Traditional Chinese Translation 2024). 📋 TSGH institutional protocol to be supplemented for comparison.
