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Pragmatic Transplant Candidacy Guidelines Ensure That Donor Lungs Go to Those Who May Benefit Most


One of the most challenging aspects of lung transplantation is deciding which patients to place on the waitlist. A myriad of factors play into the decision, including the patient’s comorbidities, physical fitness and psychosocial support system. At Emory Transplant Centerthe Lung Transplant Program is taking an iterative approach to making candidacy decisions in the effort to optimize patients who fall short

Emory is the only transplant center in Georgia that offers lung transplant surgery.

Where do lung transplant candidacy guidelines come from?

Lung transplant centers follow guidelines established by the International Society for Heart and Lung Transplantation (ISHLT). This year, for the first time since 2014, the ISHLT is revising its consensus guidelines for candidate selection. The revised guidelines reflect significant advances in the field that change the criteria for referral and listing.

The Emory Lung Transplant Program is already incorporating the new ISHLT guidelines into our candidacy process. Many criteria that were once regarded as absolute, such as a strict age cutoff of 65, are now considered relative. At Emory, we follow an integrated approach, considering age as one factor among many.

What does that iterative approach look like at Emory?

Our process rests on three pillars: the lung transplant window, medical comorbidities and the psychosocial evaluation. Getting listed isn’t easy or straightforward, but our team is committed to helping potential candidates meet the criteria—if not on the first attempt, then at a later time as the disease progresses.

How do you define the lung transplant window?

The transplant window is a theoretical construct that helps us identify the optimal time for evaluation and listing based on the patient’s survival benefit. In other words, we consider whether a person is sick enough to need the transplant yet healthy enough to benefit from it. The general criteria are that patients with end-stage lung disease should be considered for transplantation when they have a more than 50% risk of death from lung disease in the next 2 years and a more than 80% likelihood of 5-year survival from their general medical conditions.

How do comorbidities affect the decision-making process?

Some comorbidities, such as active malignancy or the use of illicit drugs, are absolute barriers to listing a patient. Many other comorbidities are relative contraindications that an experienced transplant center like Emory’s may be able to address before transplant. These could include a body mass index of more than 35, poorly managed diabetes or osteoporosis.  

How does your team optimize patients who are medically frail?

Previously, the thinking was that if a lung transplant candidate was frail, you would list them and hope their frailty improves after transplant. Now we know that frail patients do worse after transplant and need to be optimized before surgery.

If a patient is close to meeting transplant criteria but is frail, we will invite them to participate in “prehab.” Emory physical therapists have developed a protocol to build functional capacity. Patients participate in intensive pulmonary rehab five days a week that includes cardiopulmonary exercise and strength conditioning to improve their endurance, ability to stand, shuffle speed and other metrics. If patients don’t live in the Atlanta area, we try to work with their local providers to simulate this prehab regimen.

What are some of the psychosocial factors that impact eligibility for a lung transplant?

We use several standardized tools to evaluate a patient’s psychosocial fitness for transplant. Getting a lung transplant is inherently stressful and anxiety-producing, and transplant medications can exacerbate symptoms of anxiety. If a patient we are evaluating for transplant is already taking a benzodiazepine medication for anxiety, we won’t list them. However, will try to help them manage their anxiety using different medicines and behavioral therapy.

Another factor that impacts a patient’s psychosocial status is whether they have a strong support system. We want to ensure a patient has two family members or friends who will be dedicated caregivers after transplant, and we ask for a backup person, too. If that level of support isn’t there, we’ll provide coaching and support in hopes that a team will come together.

Why is it so important to follow lung transplant candidacy guidelines?

Donor lungs are a scarce resource, and there is a tremendous disparity between the number of people in end-stage lung disease and the number of suitable organs. Lung transplant programs must follow stringent guidelines to make sure we offer transplants to patients with the best chance of benefitting in terms of long-term survival and quality of life.

For more information about the Emory Lung Transplant Program or to refer a patient, call 1-855-EMORY-TX (366-7989) or visit

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