Lung transplantation is considered for patients with end-stage lung disease unresponsive to all other medical treatments. It offers a life-extending option for individuals facing severely limited life expectancy due to respiratory failure. The eligibility process is rigorous and highly selective, balancing medical necessity with the likelihood of a successful long-term outcome. The evaluation identifies patients who are sick enough to need the transplant but healthy enough to survive the operation and the demanding post-operative recovery period.
Primary Medical Conditions That Require Transplantation
Patients considered for a lung transplant suffer from irreversible, progressive pulmonary failure despite maximal medical therapy. These conditions are broadly grouped into obstructive and restrictive lung diseases, as well as diseases of the pulmonary vasculature.
Chronic Obstructive Pulmonary Disease (COPD) and its severe form, emphysema, are frequent indications when airflow limitation is profound and quality of life is severely compromised. Idiopathic Pulmonary Fibrosis (IPF) is another major category, involving progressive scarring of the lungs that often leads to a severely limited life expectancy.
Cystic Fibrosis (CF) is a genetic condition causing thick mucus buildup, chronic infections, and bronchiectasis, often requiring a double lung transplant. Pulmonary arterial hypertension (PAH) involves high pressure in the lung blood vessels, ultimately causing heart failure; transplantation is considered when medical therapies fail. These conditions, along with others like alpha-1 antitrypsin deficiency and sarcoidosis, signal a failing respiratory system.
Essential Health and Compliance Requirements for Candidacy
Candidates must possess the physical and psychological resilience necessary to withstand major surgery and the subsequent lifetime of immunosuppressive medication. Adequate function of other major organ systems is strictly evaluated, as a failing heart, liver, or kidney significantly increases surgical risk and compromises long-term survival. Poor kidney function, often indicated by a creatinine clearance below 50 mL/min, is a major concern because post-transplant anti-rejection drugs are toxic to the kidneys.
A patient’s nutritional status is also a predictor of recovery and survival. Both severe malnutrition and morbid obesity are linked to poorer outcomes; therefore, a Body Mass Index (BMI) between 18 and 35 kg/m² is generally required for listing. While age limits are often institutional, many centers prefer candidates to be physiologically under 65 or 70 years old for a double lung transplant, recognizing that older patients tend to have higher post-operative complication rates.
Psychosocial stability and a robust support network are essential, as the post-transplant regimen is complex and demanding. Candidates must demonstrate strict adherence, or compliance, with the lifelong medication schedule, frequent follow-up appointments, and rehabilitation programs. The transplant team requires the patient to identify a primary caregiver who will be available to assist with recovery and medication management.
Absolute Factors That Prevent Listing
Certain medical and behavioral factors are considered absolute contraindications that definitively disqualify a patient. Active malignancy or a recent history of cancer is a primary exclusion, as the immunosuppression required post-transplant can cause dormant cancers to recur and grow aggressively. Transplant centers typically require a disease-free interval of at least five years for most solid tumors.
Significant, uncorrectable dysfunction in a non-pulmonary organ system, such as irreversible liver cirrhosis or severe, untreatable coronary artery disease, prevents listing. The patient must be able to tolerate the surgical stress and the side effects of powerful anti-rejection medications, which is impossible if another major organ is already failing. Active, uncontrolled systemic infections, including resistant bacteria or fungi, must be eradicated before a patient can be considered.
Active substance abuse is another definitive exclusion, particularly current use of tobacco, alcohol, or illicit drugs. Most programs require documented abstinence for a minimum of six months before evaluation can begin, as these substances severely compromise post-transplant health and compliance. A documented history of non-adherence to previous medical treatment or severe, untreatable psychiatric instability are also disqualifying factors. The transplant team must be confident that the patient will reliably follow the complex, lifelong medical protocol required to maintain the new lungs.
The Evaluation and Active Waitlist Process
The path to the active waitlist begins with a referral from a pulmonologist, followed by a comprehensive, multi-step evaluation conducted by a specialized transplant center. This extensive assessment involves numerous diagnostic tests, including cardiac catheterization to assess heart function and specialized imaging to map the lungs. The evaluation also includes infectious disease screening, blood typing, and a six-minute walk test to determine the patient’s current functional capacity.
A multidisciplinary team, including transplant surgeons, pulmonologists, social workers, psychiatrists, and dieticians, reviews all data to determine candidacy. This team collectively assesses the medical, psychological, and social readiness of the patient for the procedure and the long-term commitment it demands. Upon final approval, the patient is placed on the national waiting list, managed by the Organ Procurement and Transplantation Network (OPTN).
The patient’s priority for receiving a donor lung is determined by the Lung Allocation Score (LAS). The LAS ranks candidates based on urgency and predicted post-transplant survival benefit. The score mathematically weighs a candidate’s risk of dying within the next year without a transplant against their predicted survival during the first year after the procedure. This system ensures that the limited supply of donor organs is directed toward the candidates who are both the sickest and most likely to benefit.