Who Is Eligible for a Lung Transplant?

A lung transplant may be considered when severe lung disease has progressed to the point where other treatments are no longer providing enough benefit. But having advanced lung disease does not automatically mean that a person is eligible for transplantation.

Eligibility for a lung transplant is determined through a detailed assessment of the person's lung disease, overall health, physical condition, ability to recover after surgery, and other factors that can influence long-term outcomes.

It is also important to understand that being referred to a transplant centre does not mean that a patient will definitely be listed for a transplant. Referral, evaluation, candidacy and listing are separate steps in the transplant process.

What Makes Someone a Potential Lung Transplant Candidate?

In general, lung transplantation may be considered for people with advanced, irreversible lung disease who have a poor expected outlook despite appropriate treatment and who are considered capable of undergoing the procedure and its long-term follow-up.

Conditions that may lead to consideration for transplantation include:

• Advanced chronic obstructive pulmonary disease (COPD)
• Progressive interstitial lung diseases, including some forms of pulmonary fibrosis
• Severe pulmonary hypertension
• Cystic fibrosis
• Advanced bronchiectasis
• Other severe and irreversible lung diseases

The underlying diagnosis is only one part of the assessment. The transplant team also considers how rapidly the disease is progressing, how much it limits daily life, and whether other available treatments are still controlling the condition adequately.

What Factors Are Considered During Lung Transplant Evaluation?

There is no single test that determines whether someone is eligible for a lung transplant. Instead, the transplant team builds an overall picture of the person's health and potential risks.

1. Severity and progression of lung disease

The disease generally needs to be sufficiently advanced to justify the risks associated with transplantation. Doctors may review lung function, oxygen requirements, exercise capacity, symptoms, disease progression, hospitalisations and other clinical measurements. A rapidly worsening condition may be particularly important when deciding how urgently evaluation should take place.

2. Overall physical health

Lung transplantation is major surgery, followed by lifelong medical treatment and monitoring. The body therefore needs enough overall reserve to tolerate the procedure and recovery.

The evaluation may include an assessment of the heart, kidneys, liver, nutritional status, muscle strength and other organ systems. Problems involving other organs do not always automatically rule out transplantation, but severe uncontrolled disease can substantially increase the risks.

3. Ability to participate in rehabilitation

Physical condition is an important part of transplant assessment. After surgery, patients need to participate in rehabilitation and gradually rebuild strength and physical function.

Severe frailty, very limited mobility or an inability to participate in rehabilitation can affect transplant suitability. However, physical conditioning and rehabilitation may improve some patients' status before transplantation.

4. Nutritional status and body weight

Both severe obesity and significant undernutrition can increase the risks associated with transplantation. For this reason, body weight, nutritional intake, muscle mass and overall nutritional health are assessed as part of the evaluation. 

A weight-related concern may sometimes be addressed before listing rather than being treated as an automatic reason to exclude someone.

5. Heart and other major organs

The heart and other vital organs are assessed carefully because transplantation places significant demands on the body.

Significant heart disease, kidney dysfunction, liver disease or other serious medical conditions may increase the risk of complications. In selected situations involving severe disease affecting more than one organ, combined or multi-organ transplantation may be considered.

Does Age Affect Lung Transplant Eligibility?

Age is one factor considered during transplant evaluation, but it is not necessarily the only factor that determines suitability. Older patients may have a higher risk of complications after transplantation, particularly when age is accompanied by frailty, cardiovascular disease or other significant health problems. 

The ISHLT consensus document identifies age above 70 years as a factor associated with substantially increased risk, while emphasizing that transplant centres consider combinations of risk factors and individual circumstances.

This means that chronological age should be considered alongside physical condition, organ function, disease severity and the person's ability to undergo rehabilitation and long-term treatment.

When Can a Medical Condition Make Transplantation Too Risky?

Some conditions can create a very high risk of poor outcomes after lung transplantation. The current ISHLT guidance identifies several situations that are generally considered major contraindications, although transplant decisions remain individualized.

Examples include:

• Active or uncontrolled serious infection, including active tuberculosis
• Septic shock
• Certain cancers with a high risk of recurrence or death
• Severe, irreversible dysfunction of another major organ in situations where multi-organ transplantation is not appropriate
• Recent major cardiovascular or cerebrovascular events in specified circumstances
• Severe functional limitations with little potential for post-transplant rehabilitation
• Progressive cognitive impairment that significantly affects the ability to participate in care
• Repeated serious non-adherence without evidence of improvement
• Active substance dependence, including ongoing tobacco use
• Other severe uncontrolled conditions expected to significantly limit survival after transplantation

These factors should not be interpreted as a simple self-assessment checklist. Their significance depends on the individual patient and the circumstances surrounding the condition.

What Tests Are Done During a Lung Transplant Evaluation?

A transplant evaluation is usually comprehensive. The exact investigations vary according to the patient's condition, but may include:

• Pulmonary function testing
• Chest imaging
• Exercise or walking tests
• Oxygen assessment
• Heart evaluation
• Blood and urine tests
• Kidney and liver function assessment
• Infection screening
• Cancer screening where appropriate
• Nutritional assessment
• Assessment of physical strength and functional capacity
• Psychological and social assessment

The purpose is not simply to determine whether a patient is sick enough to need a transplant. The team also needs to understand whether transplantation can be performed with an acceptable level of risk and whether the patient can manage the demanding care that follows.

What Is the Difference Between Evaluation and Being Listed?

This distinction is important.

Referral: A doctor sends a patient to a transplant centre because transplantation may eventually be appropriate.

Evaluation: The transplant team performs detailed medical, physical and psychosocial assessments to determine suitability.

Candidacy: The team determines whether the patient meets the centre's criteria to be considered for transplantation.

Listing: A patient who is considered an appropriate candidate may be placed on the transplant waiting list according to the applicable allocation system and clinical circumstances.

Therefore, being referred does not mean that a patient will necessarily receive a transplant, and being evaluated does not automatically result in listing.

The Bottom Line

Being eligible for a lung transplant involves much more than having severe lung disease. Doctors need to determine whether the underlying condition is advanced enough to justify transplantation and whether the person's overall health allows them to undergo the procedure and manage long-term treatment afterward.

Lung function, disease progression, physical condition, nutrition, heart and other organ health, infection status, smoking or substance use, medication adherence and available support can all influence the assessment.

Most importantly, eligibility is not always a permanent yes-or-no decision. Some risk factors can be treated or improved, and a patient may be reassessed as their health or circumstances change. A transplant evaluation therefore provides a detailed, individualized assessment rather than a simple checklist of eligibility requirements.