What are the current United States criteria for lung transplant?

Current United States Criteria for Lung Transplantation

Lung transplantation should be considered for patients with progressive respiratory failure despite optimal medical management who meet established criteria, with specific disease-based indications determining appropriate timing for referral and listing. 1

General Criteria for Referral and Listing

Referral Criteria

Patients should be referred for lung transplant evaluation when they have:

• Progressive respiratory disease despite optimal medical management
• Limited life expectancy without transplantation
• No significant contraindications to transplantation
• Age typically under 60 years (though this varies by center) 1

Absolute Contraindications

• Unstable or inadequate psychosocial profile/stability
• Significant extrapulmonary disorders that may negatively influence survival:
  • Severe liver dysfunction
  • Renal dysfunction
  • Cardiac dysfunction 1

Disease-Specific Criteria

For COPD Patients

Referral Criteria:

• Progressive disease despite optimal medical management
• Not a candidate for endoscopic or surgical lung volume reduction
• BODE index of 5-6
• PCO2 > 50 mm Hg (6.6 kPa) and/or PaO2 < 60 mm Hg (8 kPa)
• FEV1 < 25% predicted 1

Listing Criteria (any one of the following):

• BODE index > 7
• FEV1 < 15-20% predicted
• Three or more severe exacerbations during the preceding year
• One severe exacerbation with acute hypercapnic respiratory failure
• Moderate to severe pulmonary hypertension 1

For Pulmonary Fibrosis Patients

• Severe functional impairment
• Oxygen dependency
• Deteriorating clinical course despite optimal medical management 1

For Pulmonary Hypertension Patients

• Advanced functional class with adverse pulmonary hemodynamics despite aggressive treatment
• Progressive right ventricular failure 1
• FEV1 < 20% predicted plus either DLCO < 20% or homogenous emphysema on imaging
• Evidence of secondary pulmonary hypertension despite adequate oxygenation
• History of hospitalization with acute hypercapnic respiratory failure with PaCO2 > 50 mm Hg 1

Transplant Type Considerations

• Single lung transplantation: Currently the preferred surgical operation for many conditions including COPD 1
• Bilateral lung transplantation: Better long-term outcomes, especially for patients younger than 60 years 1
• Heart-lung transplantation: Reserved for selected patients with complex congenital heart disease or Eisenmenger syndrome 1

Important Clinical Considerations

Timing of Referral

Early referral is critical due to:

• Limited donor availability
• Waiting times that may exceed 2 years
• Risk of death while awaiting transplantation 1

Post-Transplant Outcomes

• 5-year survival after transplantation approximates 50-60% 1
• Early mortality causes: graft failure, infection, heart failure
• Late mortality causes: bronchiolitis obliterans, infection, malignancy 1

Bridging Strategies

For rapidly deteriorating patients, bridging strategies may include:

• Atrial septostomy (in selected pulmonary hypertension patients)
• Extracorporeal membrane oxygenation (ECMO)
• Ventricular assist devices 1

Common Pitfalls to Avoid

1. Delayed referral: Patients often present late in their disease course, limiting transplant options
2. Overlooking comorbidities: Thorough evaluation of extrapulmonary disorders is essential
3. Failure to optimize medical therapy: Patients should receive optimal medical management before transplantation
4. Geographic limitations: Consider the limited availability of pediatric lung transplantation programs when planning care 1

Lung transplantation represents a significant intervention that can improve survival and quality of life in carefully selected patients with end-stage lung disease, but requires thorough evaluation, early referral, and consideration of both disease-specific factors and general contraindications.