Experts explain: Here’s what Crown Princess Mette-Marit will have to go through after her lung transplant

On Wednesday morning, the Royal House of Norway announced that Mette-Marit had undergone a successful lung transplant at the Oslo University Hospital Rikshospitalet (OUS).

Many politicians and Norwegians have expressed joy at the news and have wished the Crown Princess a speedy recovery.

“We are very happy that everything has gone well so far,” said Are Holm, a professor of medicine at the University of Oslo and senior consultant and respiratory specialist at Rikshospitalet, in a press release from the Palace.

“In accordance with standard practice for all recent transplant recipients, Her Royal Highness the Crown Princess will remain admitted to Oslo University Hospital Rikshospitalet for several weeks to come. This is a routine procedure to adjust medication, manage any potential complications, and undertake rehabilitation,” Holm said.

So what will Crown Princess Mette-Marit actually go through now and in the coming weeks?

1. What happens after a lung transplant?

The first days and weeks after a lung transplant are about closely monitoring how the new lungs are functioning and detecting any complications as early as possible, said Marthe Gundersen, health advisor at the Norwegian Heart, Lung and Stroke Association (LHL).

“The patient is closely monitored in the intensive care unit and in the ward, before rehabilitation and training gradually take over. Even though the operation has been completed, it is only the beginning of a long course of treatment,” she said.

Normally, the lung transplant recipient is in the intensive care unit for one to two days and is then moved to the pulmonary department, according to the Oslo University Hospital. After about four weeks, the patient can usually go home.

“Rehabilitation often starts shortly after the operation and can last for months. The training is about building up fitness, strength and function after both a serious illness and major surgery,” Gundersen said.

2. Does a transplant rapidly improve lung function in people with severe pulmonary fibrosis?

Michael Perch is a consultant and team leader at the Department of Lung Transplantation and Pulmonary Diseases at Rigshospitalet in Denmark.

“We perform lung transplantation primarily with the aim of prolonging life. We hope that the quality of life will improve at the same time. This is the case for most people. Most people will notice better breathing function early in the process, but not necessarily everyone,” he said.

Respiratory function will normally improve after the transplant, said Solvor Findalen Pedersen at the Department of Pulmonary Medicine at Akershus University Hospital, in an email.

“Depending on how long you have been sick beforehand, many have lost a lot of muscle mass and fitness, and it can take many months to regain it,” she wrote.

The body must first recover from a very major operation, so recovery is often gradual, through rehabilitation and training, LHL’s Gundersen said.

“For many, the transplant means the opportunity to breathe easier and be more physically active than they could before the procedure,” she said.

3. What are the possible complications?

“Right after the operation, complications resulting from surgery, such as bleeding, are often possible,” Perch said.

In the days following, the patient’s medical team watches for signs of rejection or side effects from medications.

Rejection occurs because the immune system recognizes the new lungs as foreign tissue, Gundersen said.

“Immune cells, especially T lymphocytes, are activated and try to attack the transplanted organ. If this reaction is not suppressed, it can damage the lung tissue and reduce the function of the new lungs. Therefore, patients are closely monitored for signs of rejection over both the short and long term,” Gundersen said.

Rejection reactions can be both acute and chronic, said Pedersen, from the Akershus University Hospital.

“The acute reaction often does not cause symptoms, but some people may experience a slight fever, shortness of breath, cough and mucus. Regular bronchoscopies are performed where small tissue samples are taken to check for this,” she said.

 4. What happens during rejection?

Rejection reactions can usually be treated so that the end result is good, according to OUS.

The most serious complication is chronic rejection, which causes lung function to deteriorate over time. The condition can occur after a few months or several years.

“After transplantation, all patients have their lung function measured regularly. A drop in function can be a sign of rejection. Other symptoms can be shortness of breath during activity, as well as coughing,” Pedersen said.

“The body's immune system is designed to detect and capture cells and substances that are foreign, such as bacteria and viruses. A transplanted organ will be foreign even if you try to match the blood type and antibodies as best you can,” she said.

As a result, the patient must take immunosuppressive medicines.

The medications must be taken at fixed times in the morning and evening for the rest of their life and the dose must be adjusted to the individual patient, Pedersen explained.

There are no good markers for whether you are getting enough immunosuppressive medication, said Perch, from the Rigshospitalet in Denmark. To monitor this, doctors must check breathing function, the number of white blood cells in the blood and other metrics such as body temperature.

“We do bronchoscopies where we take tissue samples from the lungs that we examine with a microscope. Then you can see if white blood cells have collected around the blood vessels in the lungs. These are signs that something is happening, that the immune system is active and trying to attack the new lung,” he said.

5. How do immunosuppressive drugs work?

These drugs inhibit the function of immune cells, says Perch.

“Typically, three different types of drugs are used that act in three different places on the cells, so their function becomes worse,” he said.

But it comes at a price.

“The price is that you are more susceptible to infections, and you are more at risk of cancer, because part of the immune system's role is also to detect and destroy these changed cells. When you suppress that function, they can more easily pop up and grow,” he said.

There is a balance between the risk of acute and chronic rejection and the risk of infections, cancer and side effects of the medication in the long run, Perch said.

6. Can you live normally afterwards?

Do Mette-Marit and others who have received a transplant have to protect themselves from common illnesses such as colds and flu?

Many can live good, active lives after a lung transplant, but immunosuppressive treatment brings with it some lasting considerations, says LHL’s Gundersen.

“Because the immune system is weakened, common infections can become more serious than in others. Therefore, patients must be more aware of preventing infection, and must follow up on vaccinations and seek medical help if there are signs of infection,” she said.

“At the same time, the goal of the transplant is that the patient should be able to have a better, more active life than before the operation,” she said.

Lung transplant recipients are at risk of getting sick from bacteria, viruses and fungi that don’t make normal healthy people sick because the transplant recipient has a suppressed immune system,” Pedersen said.

“Infections such as Covid or influenza cause more serious and prolonged illness than in healthy people. A person with a transplant has to be extra careful in preventing infections, but can otherwise live almost normally,” she says.

It is important to avoid being with people who are clearly sick, including small children, Perch said.

Mette-Marit has a very public role and meets many people. Do you think it could be difficult for her to have exactly the same role as before?

“That does seem likely,” says Perch.

Are there any other ways that taking immunosuppressive medication limits your life?

“It's a bit individual. Some people have side effects that can be limiting. Others don't notice it that much. But you have to take the medication for the rest of your life,” he said.

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Translated by Nancy Bazilchuk

Read the Norwegian version of this article at forskning.no

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