ISHLT Consensus
A consensus document for the selection of lung transplant candidates: 2014—An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation

https://doi.org/10.1016/j.healun.2014.06.014Get rights and content

The appropriate selection of lung transplant recipients is an important determinant of outcomes. This consensus document is an update of the recipient selection guidelines published in 2006.

The Pulmonary Council of the International Society for Heart and Lung Transplantation (ISHLT) organized a Writing Committee of international experts to provide consensus opinion regarding the appropriate timing of referral and listing of candidates for lung transplantation. A comprehensive search of the medical literature was conducted with the assistance of a medical librarian. Writing Committee members were assigned specific topics to research and discuss. The Chairs of the Writing Committee were responsible for evaluating the completeness of the literature search, providing editorial support for the manuscript, and organizing group discussions regarding its content.

The consensus document makes specific recommendations regarding the timing of referral and of listing for lung transplantation. These recommendations include discussions not present in previous ISHLT guidelines, including lung allocation scores, bridging to transplant with mechanical circulatory and ventilator support, and expanded indications for lung transplantation.

In the absence of high-grade evidence to support decision making, these consensus guidelines remain part of a continuum of expert opinion based on available studies and personal experience. Some positions are immutable. Although transplant is rightly a treatment of last resort for end-stage lung disease, early referral allows proper evaluation and thorough patient education. Subsequent waiting list activation implies a tacit agreement that transplant offers a significant individual survival advantage. It is both the challenge and the responsibility of the transplant community globally to ensure organ allocation maximizes the potential benefits of a scarce resource, thereby achieving that advantage.

Section snippets

How to use this document

The decision to place a patient on the waiting list for a lung transplant is complex, reflecting consideration not only of clinical and psychosocial characteristics of the individual patient but also program-specific factors and regional considerations (e.g., the influence of a lung allocation system). The referral of a patient to a transplant center should not be interpreted by the patient, referring physician, or the program as an automatic endorsement of listing that individual, either at

Methods

At the ISHLT Annual Scientific Meeting in 2012, the Pulmonary Transplantation Council of the ISHLT proposed revising the recipient selection criteria, which were last updated in 2006. The Council leadership solicited interest in participating in the formulation of this document. A Writing Committee was proposed and approved by the Standards and Guidelines Committee in late 2012. The Writing Committee reflected the diverse nature of the Pulmonary Transplantation Council with regard to geographic

General candidacy considerations

Lung transplantation should be considered for adults with chronic, end-stage lung disease who meet all the following general criteria:

  • 1.

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

  • 2.

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

  • 3.

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

Previous surgery

Recommendations:

  • Previous surgery is not a contraindication to lung transplantation.

  • Pleurodesis is the most troublesome situation but is not a contraindication.

  • Pneumothorax in a patient who may become a future transplant recipient should be given the best immediate management. The choice of intervention is unlikely to affect future acceptance for transplantation.

  • Higher rates of bleeding, reexploration, and renal dysfunction are to be expected in patients with previous chest procedures. These

Interstitial lung disease

Timing of referral:

  • Histopathologic or radiographic evidence of usual interstitial pneumonitis (UIP) or fibrosing non-specific interstitial pneumonitis (NSIP), regardless of lung function.

  • Abnormal lung function: forced vital capacity (FVC) <80% predicted or diffusion capacity of the lung for carbon monoxide (Dlco) <40% predicted.

  • Any dyspnea or functional limitation attributable to lung disease.

  • Any oxygen requirement, even if only during exertion.

  • For inflammatory interstitial lung disease (ILD),

Lung retransplantation

Lung retransplantation accounts for a small percentage of lung transplants performed annually. However, its frequency has increased in recent years. This trend has been particularly prevalent in North America and coincided with the introduction of the LAS system in 2005 in the United States. Although many of these patients would previously have been too ill to survive prolonged waiting times, the LAS system has allowed them priority access to available donor organs.66, 67

The criteria for

Conclusions

The current 2014 consensus document represents a continuum of thought processes developed previously in the 1998 and 2006 Guidelines but extends the scope of referral and active listing criteria to consider pediatric recipients, mechanical bridge to transplant in particular with ECLS, and retransplantation to fine-tune organ donor allocation and maximize community benefits of a scarce resource. In effect, the Writing Group's response to these challenging new areas exemplifies the natural

Disclosure statement

The Writing Committee acknowledges the assistance of ID Council members, specifically Drs Margaret Hannan, Erik Verschuuren, Lara Danziger-Isakov, and Paolo Grossi, who gave recommendations regarding potential recipients infected with hepatitis B, hepatitis C, and HIV. For readers who are interested in ID Council comments regarding recipient selection in heart transplantation, the Writing Committee recommends review of the 2014 Recipient Selection Guidelines for Heart Transplantation.

None of

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