according to the statistical analysis of the international society of heart and lung transplantation , survival after lung transplantation systematically improves .
88% of recipients survive three months after operation , 79% survive for one year , and about 50 - 60% of recipients survive five years after transplantation .
the most common indication for lung transplantation is chronic obstructive pulmonary disease ( copd ) ( 34% ) .
the major early causes of death are graft failure and non - cmv infections , bronchitis obliterans syndrome ( bos ) , chronic lung rejection , and graft failure after one year .
a 58-year - old female with hyperthyroidism , osteoporosis , and copd in the fourth stage was classified for lung transplantation in 2011 .
additional tests demonstrated pao2 ( partial pressure of oxygen ) 61.2 mmhg , paco2 ( partial pressure of carbon dioxide ) 44 mmhg ( on oxygen therapy 2 l / min ) , fev1 ( forced expiratory volume in 1 second ) 0.44 l 
19.7%sd , fvc ( forced vital capacity ) 1,38,8% sd , 6-mwt ( six - minute walk test ) 174 metres , rvsp ( right ventricular systolic pressure ) 36 mmhg , and pra ( panel reactive antibody ) 3% . after four months of expectation a 57-year - old female donor , who died because of cerebral haemorrhage and was ventilated for 48 hours with pao2/fio2 360 mmhg , was identified .
both women were characterised by comparable growth and identical blood group . the day after donor identification the transplantation was performed . for this purpose
the right pulmonary vein cuff proved to be very short and tight , so it was decided to implant the left donor lung in the recipient 's right emphysemal lung locus .
elements of the recipient 's right lung hilum were dissected , cut distally with clamping of the pulmonary artery and pulmonary veins cuff .
after preparation the left donor 's lung was implanted in the contralateral position . in conjunction with different bronchus diameters
the donor bronchus was telescopically placed in the recipient 's bronchus and stitched with single absorbable sutures 3 - 0 .
two drains were inserted in the pleural cavity , and closure of the thorax was carried out .
metal suturing of the sternum and the suturing of the periosteum of the fifth rib and layered lid suture were performed ( fig .
the patient was transferred to the intensive care unit ( icu ) , where she stayed for eight days . because of retrospectively positive cross - match it was necessary to implement five automatic plasmapheresis and to apply human immunoglobulin and rituximab to diminish concentration of lymphocytotoxic antibodies against hla antigens . on the third day after transplantation the primary graft dysfunction and rising emphysema of the recipient 's own lung shifted the mediastinum towards the graft side . as well as standard treatment ,
c1-esterase was provided to deplete the extracapillary exudation , and the operative ( lung volume reduction surgery  lvrs ) reduction of emphysemal changed lung tissue was pursued with complication of prolonged air leakage ( fig .
the patient needed infusion of 16 units of fresh frozen plasma ( ffp ) , 2 units of packed red blood cells ( prbcs ) , and 100 ml of 20% albumin .
the right lung drainage was removed after seven days and the left one after 35 days .
on the 44 day after transplantation the patient was discharged from hospital with the following study results : po2 68.9 mmhg , pco2 44.0 mmhg ( without oxygen therapy ) , fev1 1.12 - 50.5% , fvc 1.38 - 52.2% , 6-mwt 246 metres , and with recommendation of taking immunosuppressing medications such as : 50 mg of cyclosporine twice a day , 1000 mg of mycophenolate mofetil twice a day , and 10 mg of prednisone once a day .
3 ) . it was histopathologically confirmed and antibodies against donor antigens were detected ( anti - hla class ii 158.57 - 701.89 mfi ) . on the third day the therapy with methylprednisolone was pursued . in chronically treatment instead of cyclosporine the tacrolimus of 0.5 mg a day was implemented .
additionally , the hospitalisation was complicated by moraxella catarrhalis infection , so amoxicillin with clavulanic acid was applied .
diagnostic tests performed meanwhile showed transient renal failure , ion disorders , hypoproteinaemia , and leukopaenia . at the turn of fifth and sixth month after transplantation
the next complications occurred : bronchitis caused by corynebacterium pseudodiphtericum , and escherichia coli urinary tract infection , both treated with amoxicillin and clavulanic acid , and a second episode of acute graft rejection . during the next two months e. coli sepsis was seen and was treated with ceftazidime
. then the cytomegalovirus disease treated with ganciclovir , pulmonary embolism , and anxiety disorder treated with opipramol and venlafaxine occurred . on account of leukopenia 2900/l
after the next month the third episode of acute graft rejection appeared , following bacterial infection caused by pseudomonas aeruginosa cured with ciprofloxacin and ceftazidime and bilateral otitis with sinus and temporal bone polyposis development , hence clindamycin and budesonide inhalation were applied .
because of hypogammaglobulinaemia it was decided to assign human immunoglobulins every three weeks . during the 11 and 12 month after the transplantation ( fig .
4 ) the next bacterial infections caused by acinetobacter baumanii , proteus mirabilis , candida albicans , c. glabrata and aspargillus species ensued . the therapy contained cefuroxime , imipenem , ampicillin with sulbactam , amikacin , amphotericin b , itraconazole , and colistin .
meanwhile drug - induced diabetes with rapid decompensation occurred , which initially needed glimepiride and then insulin therapy .
later , renal failure and a fourth episode of acute lung rejection appeared . between the 14 and 16 month after lung transplantation
the fifth episode of rejection appeared , renal failure deepened , and destabilisation of diabetes occurred .
the cytomegalovirus disease activated and valganciclovir was used in therapy , but the leukopaenia deteriorated and it was necessary to reduce the dose of the drug .
in addition , acinetobacter baumani , klebsiella pneumoniae , and candida albicans infections appeared . in therapy
the ceftazidime , ciprofloxacin , ampicillin with sulbactam , colistin , metronidazole , tazobactam , itraconazole , and nystatin were used . at this time
unfortunately , the psychological state of the patient gradually worsened , and she manifested symptoms of depression .
collateral complication appeared as posttraumatic haematoma of the shin , which required vac - therapy ( vacuum assisted closure  vac ) .
498 days after transplantation the patient died due to symptoms of sepsis after unsuccessful reanimation .
two drains inserted in right pleural cavity and catheter in right carotid internal vein are visible chest x - ray performed after lung volume reduction surgery ( lvrs ) chest x - ray performed during first episode of acute rejection chest x - ray performed one year after transplantation
lung transplantation in medically incurable patients is the only method that gives a chance to lengthen their lives .
currently it is recommended that the cross - match be pursued before performing the transplantation to avoid such a situation , although there are some scientific reports discussing the primary existence of these antibodies in the recipient 's organism or their appearance as the consequence of transplanted organ dysfunction .
there are some case reports that adduce false positive and false negative pre - transplant virtual cross - matches .
however , virtual cross - match should be considered as a routine technique used before transplantation procedure in poland .
virtual cross - match is the admitted method of prediction if the recipient produces hla - antibodies .
an appropriate computer program determines every hla antigen immunogenicity that is incompatible with full recipient hla haplotype as an inconsistent immunogenic loci ( miss - match amino acids eplets  mmep ) .
safe immunogenic incompatibility that does not result in humoral response can also be predicted with this method .
it is a huge advantage in patients who need multiple transplantations . extending the scope of immunological selection to hla - cw , dq
, dp increases the effectiveness of virtual cross - match ( 91% ) in comparison to serological selection on hla - a , b , dr used in poland .
difficulties in proper donor selection are related with imperfection of chemical reagents and antibody detection techniques . in the first case
the chance for transplantation is wasted , in the second the patient is exposed to serious postoperative complications . furthermore , the role of antibodies against the host 's own ( personal ) antigens in pathogenesis of chronic dysfunction of transplanted organs is discussed .
however , no matter which hypothesis is accepted , only quickly implemented therapy can improve the patient 's condition .
there are some ambiguous reports about monoclonal antibodies although there are some indications that such treatment can be effective [ 6 , 7 ] .
we proceeded with mandatory cross - match before lung transplantation in every recipient with pra > 0% . also ,
the age of qualified donors is limited to 55 years old , whereas the criterion of pao2/fio2 was raised to > 400 mmhg .
the recommended operation technique is bilateral lung transplantation because of the reservoir of microorganisms in the recipient 's own lung , so nowadays in such a clinical situation probably reconstruction of the donor 's right pulmonary vein cuff would be performed .
additionally , lvrs , according to present knowledge , would not be pursued , because the shading of the graft after transplantation was caused by primary graft dysfunction and not by the recipient 's own lung .
finally , meticulous training of the transplantation team in surgical techniques should be continued , which is achieved in our case by practicing microsurgical techniques on rats and by using a cadaver workshops .
 lung transplantation is a method useful in such non - malignant end - stage parenchymal and vascular diseases as : chronic obstructive pulmonary disease ( copd ) , idiopathic interstitial pulmonary fibrosis , cystic fibrosis , or primary pulmonary hypertension . 
 the main aim of this procedure is to extend the patient 's lifespan and quality of life . 
 however , the availability of the operation is limited by organ access . in this paper 
 we present the case of a 58-year - old female in the fourth stage of copd , who was classified to have a single lung transplantation . because of some technical problems it was decided to transplant a left donor lung in the right recipient lung locus . 
 positive cross match was demonstrated retrospectively , and we applied five courses of plasmapheresis . 
 human immunoglobulin and rituximab treatment were performed to decrease the impact of lymphocytotoxic antibodies . 
 the patient survived 498 days after transplantation , 271 in the hospital . 