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Lung transplantation — the basics

Lung transplantation is for a patient with end-stage lung disease who is expected to die from it despite optimal treatment and has no contraindications; the main indications are ILD (mostly IPF), COPD, CF and PAH, the lethal early complication is primary graft dysfunction, and the main late complication is chronic rejection (CLAD/BOS).

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Why it matters in the exam

The exam asks when to refer, who is not a candidate, which type of transplant fits and which complication fits the period. In ILD referral is early — already at diagnosis of IPF — because the disease progresses fast; in COPD the BODE index is used, and referral fits from a BODE of 5 or more. In CF and bronchiectasis a bilateral transplant is mandatory, because a remaining infected lung would contaminate the graft. Contraindications according to ISHLT 2021 include active or recent cancer, a BMI of 35 or more, active smoking or substance use, uncontrolled infection, significant failure of another organ and non-adherence.

Complications by time: in the first 72 hours — primary graft dysfunction (PGD), non-cardiogenic pulmonary oedema and impaired oxygenation; in the first weeks — bronchial anastomotic complications (because the bronchial arteries are not reconnected), acute rejection diagnosed by transbronchial biopsy, and infections (CMV is the commonest opportunistic infection, and also Aspergillus). Late — chronic rejection (CLAD), defined as a persistent fall of 20% or more in FEV1 from the best baseline value, and the leading cause of death after the first year; and post-transplant lymphoproliferative disease (PTLD) linked to EBV. Typical immunosuppression combines tacrolimus, mycophenolate and steroids, and median survival is only about 6 years — lower than after other organ transplants.

Remember also that a patient with severe PAH and irreversible right heart failure may need a heart-lung transplant. After transplant the patient stays under close lifelong follow-up, with home spirometry and periodic tests, to detect rejection and infection early.

Key points

• Main indications: ILD, COPD, CF, PAH.
• CF and bronchiectasis — bilateral only.
• BMI of 35 or more — a contraindication.
• PGD early; CLAD late.
• CMV is the commonest opportunistic infection.

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Sources

• ISHLT consensus document for the selection of lung transplant candidates, 2021 — Referral, listing and contraindications
• ISHLT consensus report: Chronic lung allograft dysfunction, 2019 — Definition, diagnostic criteria and grading
• ISHLT International Thoracic Organ Transplant Registry report, 2019 — Adult lung transplantation

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.