Lung Transplant

All Transplants

Background

• On average 150 lung transplants are performed each year, most commonly for COPD (40%)

• Lung Transplant comes with substantial risks and are offered in those with end stage respiratory disease without frailty

Assessment

Presentations

• Progression of severe respiratory disease

• Post transplant rejection:

  • Acute rejection

  • Chronic failure (Bronchiolitis Obliterans)

Examination

• Other scars: tracheostomy, portacath/ Hickmann/ PICC

• Examination may be normal +- finger clubbing

• Signs of medication: 

  • Fine tremor (tacrolimus), gum hypertrophy (cyclosporin- renal failure), 

  • Diabetes - moon face, libra (pred),

Investigations

• Post transplant acute presentation

  • Tacrolimus level

  • Pulmonary Function Tests

  • CXR +- CTPA or CT-T

  • Consider ddimer/ CTPA

Indications & Contraindications

Diagnoses:

• COPD, ILD, CF/ bronchiectasis, Pulmonary HTN

• Commonest- COPD 40% improves QoL > quantity, BODE index > 7yrs

• Finger clubbing: CF/ bronchiectasis, ILD

Indications

• Severe lung disease: > 50% risk of death in 2yrs without transplant

• Functional reserve

  • > 80% Survive 90 days post transplant

  • > 80% of 5yr post transplant survival (with functioning transplant)

Contraindications

• Absolute

  • Malignancy within 5 yrs

  • Organ vital failure- liver, renal, lung, brain, cardiac (unless 

  • Severe infection- e.g. mycobacterium abscessus, burkhodelia

  • Frailty, BMI > 30, smoking/ recreational drugs

  • Compliance issues- psychosocial issues,

• Relative: age > 65 yrs

Complications

• Acute rejection, opportunistic infections

• Chronic rejection: Bronchiolitis obliterans- terminal event

• Infections

• Malignancy: post transplant lymphoproliferative disease, skin

• Median survival 6 yrs

Management

MDT

• Transplant centre: early referral, contact during admission

Lifestyle

• Smoking cessation

Medical

• Anti-rejection: tacrolimus, MMF, prednisolone

• Prophylaxis: antibiotic, cotrimoxazole (PJP)

Surgical

Transplant Subtypes

Single

• Examination: 

  • Postero-lateral thorocotomy scar

  • Examine other lung ?COPD/ ILD

• Indications: ILD, COPD, 

Double 

• Examination

  • Clampshell anterior scar 

  • Normal expansion, percussion, auscultation if working

• Indications: 

  • Classically suprarutive disease- CF/ bronchiectasis, generalised bronchiectasis

  • Also ILD with pulmonary HTN

Cardiac and lung transplant

• Scar: midline sternotomy + lateral Thoracotomy

• Indications

  • Lung disease (ILD/ Bronchiectasis/ COPD) with core pulmonale

  • Congenital heart & lung disease: Eisenmenger Syndrome

  • Systemic diseases such as Sarcoidosis

References and Resources

Written in 2025