Which organization has released guidelines on the timing of referral and listing for lung transplantation?

Updated: Aug 19, 2019
  • Author: Bryan A Whitson, MD, PhD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Answer

In 2014, the International Society for Heart and Lung Transplantation (ISHLT) released an updated consensus opinion regarding the appropriate timing of referral and listing of candidates for lung transplantation. The statement concluded that lung transplantation should be considered for adults with chronic, end-stage lung disease who meet all the following general criteria [16] :

  • High (>50%) risk of death from lung disease within 2 years if lung transplantation is not performed.

  • High (>80%) likelihood of surviving at least 90 days after lung transplantation.

  • High (>80%) likelihood of 5-year post-transplant survival from a general medical perspective provided that there is adequate graft function.

Absolute contraindication include [16] :

  • Malignancy in the last 2 years, with the exception of non-melanoma localized skin cancer that has been treated appropriately (a 5-y disease-free interval is prudent)

  • Untreatable advanced dysfunction of another major organ system unless combined organ transplantation can be performed

  • Atherosclerotic disease with suspected or confirmed end-organ ischemia or dysfunction and/or coronary artery disease not amenable to revascularization.

  • Acute medical instability such as acute sepsis, myocardial infarction, and liver failure.

  • Uncorrectable bleeding diathesis.

  • Chronic infection with highly virulent and/or resistant microbes that are poorly controlled pre-transplant.

  • Active Mycobacterium tuberculosis infection.

  • Significant chest wall or spinal deformity expected to cause severe restriction after transplantation.

  • Obesity (body mass index ≥35.0 kg/m2).

  • History of repeated or prolonged episodes of non-adherence to medical therapy that are perceived to increase the risk of non-adherence after transplantation.
  • Psychiatric conditions associated with the inability to cooperate with the medical/allied health care team and/or adhere with complex medical therapy.

  • Absence of an adequate or reliable social support system.

  • Severely limited functional status with poor rehabilitation potential.

  • Substance abuse or dependence. Meaningful and/or long-term participation in therapy should be required before offering lung transplantation. Serial blood and urine testing can be used to verify abstinence from substances that are of concern.

Relative contraindications include:

  • Adults >75 years old are unlikely to be candidates for lung transplantation in most cases. Although age by itself should not be considered a contraindication to transplant, increasing age generally is associated with comorbid conditions that are either absolute or relative contraindications.

  • Obesity (BMI 30.0–34.9 kg/m2)

  • Progressive or severe malnutrition.

  • Severe, symptomatic osteoporosis.

  • Prior chest surgery with lung resection.
  • Mechanical ventilation and/or extracorporeal life support (ECLS). 

  • Infection with highly resistant or virulent bacteria, fungi, and certain strains of mycobacteria (e.g., chronic extrapulmonary infection expected to worsen after transplantation).

  • Patients with atherosclerotic disease at risk for end-organ disease after lung transplantation; with regard to coronary artery disease, some patients will be candidates for percutaneous coronary intervention or coronary artery bypass graft (CABG) preoperatively or, in some instances, combined lung transplant and CABG. 

  • Lung transplantation can be considered in patients infected with hepatitis B and/or C who are stable on appropriate therapy without significant clinical, radiologic, or biochemical signs of cirrhosis or portal hypertension. Lung transplantation in candidates with hepatitis B and/or C should be performed in centers with experienced hepatology units.
  • Lung transplantation can be considered in HIV-positive patients with undetectable HIV-RNA, and compliant on combined anti-retroviral therapy. The most suitable candidates should have no current acquired immunodeficiency syndrome–defining illness. Lung transplantation in HIV-positive candidates should be performed in centers with expertise in the care of HIV-positive patients.

  • Lung transplantation can be considered in patients infected with Burkholderia cenocepaciaBurkholderia gladioli, and multi-drug–resistant Mycobacterium abscessus if the infection is sufficiently treated preoperatively and there is a reasonable expectation for adequate control postoperatively. To be considered suitable transplant candidates, these patients should be evaluated by centers with significant experience managing these infections in the transplant setting, and patients should be made aware of the increased risk of transplant because of these infections.

  • Other medical conditions that have not resulted in end-stage organ damage, such as diabetes mellitus, systemic hypertension, epilepsy, central venous obstruction, peptic ulcer disease, or gastroesophageal reflux, should be optimally treated before transplantation.


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