Who needs a lung transplant? - Dr. Manjunath M N

In my practice at KIMS Hospital, Electronic City, the most common question patients and families ask is: “Have we waited too long - or is it too early to even consider this?” Both questions matter. Referring too late costs lives; referring too early creates anxiety. This article explains, in plain language, who actually benefits from lung transplantation and how the decision is made.

What lung transplantation does

A lung transplant replaces one or both diseased lungs with healthy lungs from a deceased donor. It does not cure the underlying disease in the recipient - the goal is to restore breathing, quality of life and longevity. Most patients return to school, work, and active life within 3-6 months of surgery, on lifelong immunosuppression.

In India, lung transplantation is now an established option at high-volume centres. KIMS’s thoracic transplant programme has completed over 750 transplants - among the largest in Asia - and I have personally managed more than 250 lung transplant cases across evaluation, ECMO support, surgery, and long-term follow-up.

Who benefits

The most common conditions that lead to lung transplant are:

• Interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF) - the single largest indication globally and at KIMS
• Chronic obstructive pulmonary disease (COPD) - severe emphysema or alpha-1 antitrypsin deficiency
• Pulmonary hypertension, including primary and Eisenmenger physiology
• Cystic fibrosis and non-CF bronchiectasis with end-stage destruction
• Sarcoidosis with fibrotic lung involvement
• Post-COVID and post-tuberculosis fibrotic destruction - an increasingly common indication in the Indian context
• Acute irreversible lung injury, in selected cases, where ECMO is acting as a bridge to transplant

The trajectory matters more than the diagnosis

What ties these conditions together is not the diagnosis itself but the trajectory. A patient with IPF stable on antifibrotics may not need transplant for years; a patient with the same diagnosis whose 6-minute walk distance is dropping every 3 months and who needs increasing oxygen probably does.

The signals that say “refer for evaluation now”

Regardless of the specific diagnosis, certain warning signs should trigger an immediate transplant referral - not after the next exacerbation, not after the next admission. Now.

Red-flag signs

• Need for supplemental oxygen at rest or with minimal activity
• Progressive drop in lung function (FVC or DLCO) over months despite optimal therapy
• Hospitalisations for respiratory failure, especially requiring non-invasive ventilation or ICU care
• Rising pulmonary artery pressures on echocardiogram or right heart catheterisation
• Weight loss, increasing breathlessness on minimal exertion, or new resting tachycardia
• 6-minute walk distance below 350 metres, or a fall of more than 50 metres over 6 months
• An acute event - sudden deterioration that places the patient on mechanical ventilation or ECMO

Thresholds, not strict cutoffs

These numbers are guideposts. A pulmonologist familiar with transplant assessment will weigh them in the context of the underlying disease - a borderline 6-minute walk in a young cystic-fibrosis patient on a steep trajectory may be more concerning than a worse number in a stable older patient.

The wrong outcome is the patient who arrives at our ICU on a ventilator with no prior contact. That outcome is almost always preventable with an earlier referral.

Who is not a candidate

Transplant is not the right answer for every patient with severe lung disease. The following are usually contraindications:

Absolute and near-absolute contraindications

• Active malignancy (with limited exceptions for localised skin cancers)
• Active infection outside the lungs that cannot be cleared
• Severe disease in another vital organ - heart, liver or kidney - that the patient could not survive
• Active substance use, including tobacco and harmful alcohol use
• Severe frailty or sarcopenia that would prevent rehabilitation after surgery
• Inability to adhere to lifelong immunosuppression or follow-up - for medical, psychological or social reasons

Most are relative, not absolute

Many of these are relative rather than absolute. A patient who quits smoking and proves 6 months of abstinence may become a candidate. A patient with kidney dysfunction may be assessed for combined lung-and-kidney transplant. Each case is reviewed individually by the multi-disciplinary team - rejection on a single line item is rare.

What the evaluation actually involves

Four core objectives

The work-up has four objectives:

1. Confirm the diagnosis and the stage of disease
2. Establish that there are no contraindications
3. Match the patient with the right type of transplant (single lung, bilateral lung, or combined heart-and-lung)
4. Build the donor compatibility profile (blood group, HLA, anti-HLA antibodies, viral status)

What the work-up looks like in practice

Evaluation includes pulmonary function tests, cardiac catheterisation in some cases, full-body imaging, a 6-minute walk test, dental and ENT clearance, infectious disease screening (HIV, hepatitis, tuberculosis, CMV, EBV), nutritional assessment, and psychosocial review. For most ambulatory patients this takes 1-3 weeks. For unstable patients on ECMO, we compress it into days.

What happens after listing

How allocation works in India

Once a patient is accepted, they are added to the national organ allocation list maintained by NOTTO (National Organ and Tissue Transplant Organization) and the regional ROTTO. Allocation is based on blood group, body size, time on the list, and medical urgency. Waiting times in India range from a few weeks (for blood group AB, small donor, urgent need) to several months (for blood group O, large recipients, stable patients).

Staying transplant-ready during the wait

The goal during the wait is to keep the patient as fit as possible - pulmonary rehabilitation, nutritional support, vaccinations, prompt treatment of any infections, and tight control of cardiovascular risk factors. Patients who arrive at surgery in better shape recover faster, leave the ICU sooner, and have markedly better one-year outcomes.

The most important point

If you or your treating physician are even considering whether transplant might be relevant, that is the right moment for a specialist opinion - not later. An early conversation almost always helps: in many cases I tell patients they have 1-2 years of medical therapy left before transplant is required, which gives time to plan, build family support, and stay on the watch list. In other cases the conversation prompts immediate listing that saves a life.

The wrong outcome is the patient who arrives at our ICU on a ventilator with no prior contact, where we are forced to do an emergency evaluation under ECMO with markedly worse odds. That outcome is almost always preventable with an earlier referral.

Related reading: our lung transplantation programme · Lung transplant cost in India · ECMO as bridge to recovery vs transplant · Post lung transplant airway interventions