For 10 years, she couldn’t breathe without oxygen. At 65, a double lung transplant gave her second life

“Survival rates are heavily influenced by the recipient’s age at the time of the transplant, alongside their underlying diseases and adherence to lifelong medications. Once patients survive the initial year, their immunosuppressive therapy usually stabilises and the risk profile improves significantly. Our patient did not have diabetes or hypertension and is disciplined about behaviour. She has not stepped out of the house for a year except while visiting us for follow-ups. She is masked before outsiders and can gradually go visiting her friends but avoid crowded, outdoor spaces. This way she can prevent infection,” says Dr Avdhesh Bansal, senior consultant, Respiratory Medicine, Indraprastha Apollo Hospital, New Delhi.

“Lung transplant is the most complex procedure as compared to other transplants. Completing one year after a bilateral lung transplant is a significant milestone, especially in a case as complex as this. When the patient first came to us, her lungs were failing rapidly, and she required continuous oxygen support. Now she has regained quality of life,” he adds.

The disease that slowly destroyed her lungs

Bhowmick developed interstitial lung disease, or ILD, when inflammation gradually scars the lungs, leading to fibrosis. “Her trigger was linked to scleroderma, an autoimmune disorder in which the immune system attacks the body’s own tissues. Under normal conditions, oxygen inhaled through the lungs passes into tiny air sacs called alveoli before entering the bloodstream. Fibrosis disrupts this transfer mechanism. As scarring worsens, patients struggle to oxygenate their blood adequately even while resting,” says Dr Bansal.

Diagnosed in 2011, Bhowmick required four to five litres of oxygen daily by 2016, just to survive. Even at rest, her oxygen saturation would plunge dangerously low. Although she was on steroids and anti-fibrotic medication, she quickly progressed to end-stage lung failure. Walking across a room became exhausting. Cooking, climbing stairs or stepping outdoors without oxygen support was nearly impossible. “Before the transplant, I was completely dependent on oxygen 24 hours a day. Even simple daily activities like taking a bath, changing clothes, or going into the kitchen had become extremely difficult. Today, I can do all these things independently and no longer require oxygen support. I feel more energetic and full of life. The journey after the transplant was also not easy. I had to take medicines at the same time, and undergo frequent medical and blood check-ups. Maintaining proper nutrition was important. But now things have become much easier. I am slowly getting back to normal life and can step out while following precautions,” says Bhowmick.

Why lung transplant is so challenging

Unlike kidney or liver transplantation, lung transplantation presents unique risks because the lungs are continuously exposed to the external environment through breathing. Every breath potentially introduces infections, pollutants and fungal spores into immunosuppressed patients.

The donor lungs in this case came from a 48-year-old brain-dead donor. Dr Mukesh Goel, cardiothoracic surgeon, Indraprastha Apollo Hospital, New Delhi, recalls the six-month wait for the right donor. “Matching involves far more than blood group compatibility. Surgeons must ensure the donor lungs are healthy, free of infection and structurally suitable for implantation. Donor age also matters significantly, with lungs from donors above 60 generally considered less ideal,” he says.

The transplant itself was extensive; the surgery implantation process took nearly 12 hours. “After surgery, the patient spent between 10 and 15 days in intensive care and remained hospitalised for approximately three weeks before being discharged,” says Dr Goel.

Even after successful surgery, complications can emerge. In her case, doctors had to manage bronchial narrowing, a complication in which parts of the airway become constricted after transplantation. “She underwent repeated dilation procedures to widen the airway and improve airflow,” says Dr Goel.

How doctors monitor for organ rejection

Lung transplant recipients require lifelong monitoring because rejection can occur even years after surgery. “We use multiple tools to detect rejection early, including bronchoscopy, lung biopsies, lung function tests and increasingly, specialised cell-free DNA testing that detects donor organ injury at a molecular level. Viral infections can also trigger inflammatory reactions that mimic or worsen rejection episodes,” says Dr Bansal.

Families are trained to watch for warning signs such as breathlessness, fever, declining exercise tolerance, persistent cough or falling oxygen levels. “Rejection episodes can be treated successfully with medication if detected early,” he adds.

The lifelong burden of immunosuppression

To prevent the immune system from attacking the transplanted lungs, patients must take lifelong immunosuppressive medications. “Tacrolimus remains one of the most important drugs in lung transplantation. However, maintaining appropriate blood levels is crucial because the drug interacts with diet and other medications. Certain foods, particularly grapefruit, can dangerously alter tacrolimus metabolism. Patients must also avoid many over-the-counter medications unless cleared by transplant specialists. Common drugs such as Allegra, cetirizine, antacids and paracetamol are generally manageable, but any additional prescription medication requires cross-checking because drug interactions can destabilise immunosuppressant levels,” says Dr Bansal.

For the first six months after transplantation, immunosuppression doses are usually kept particularly high before gradually being reduced to maintenance levels.

Bhowmick has been advised to avoid dust. “Fungal spores are widespread in dusty urban environments, making fungal pneumonia a constant concern in lung transplant recipients. Tuberculosis also remains a major risk because many Indians carry latent TB infection acquired during childhood exposure. Under immunosuppression, dormant TB bacteria can reactivate. That’s why social distancing protocol, avoiding polluted areas and hand hygiene become so important,” says Dr Bansal.

Vaccination planning is crucial in transplant medicine. Doctors prefer most vaccinations to be administered before transplantation whenever possible. After transplantation, inactivated vaccines are generally considered safer, while certain live or newer immune-stimulating vaccines may require specialist review. “Travel is only possible to an area which has transplant-capable medical centres during emergencies. International travel requires even more careful planning because complications can escalate rapidly,” advises Dr Bansal.

The cost challenge

While outcomes are improving, costs, delayed referrals and infection burdens remain major challenges. “Many transplants in India are still not comprehensively covered by insurance. Total costs may range between ₹70 lakh and ₹1 crore depending on complications and long-term care needs,” says Dr Bansal. And while immunosuppressants are expensive, he says the ones made by reliable companies are also available at Jan Aushadhi centres. “Since they are relatively low in demand, we have not seen fake drugs in this category,” says Dr Bansal.

But the larger point is organ donation. “There is a shortage of viable organs: only 15 to 20 per cent of donated lungs are typically suitable for use and some patients on waiting lists do not survive long enough to receive one. Bhowmick has a second life because of the donor’s family,” he says.