Guidelines on transplantation for COVID-19-related irreversible lung injury

The ISHLT and the Toronto Group have both made recommendations on how to achieve optimal lung transplant outcomes.

With widespread prolonged ventilation and treatment with extracorporeal membrane oxygenation (ECMO), it is inevitable that some COVID-19 patients will emerge with irreversible lung injury. Very few guidelines exist, but the ISHLT recently outlined some general precautions(10), including:

  • No changes to induction immunosuppression from the institution’s standard protocol.
  • Continue maintenance immunosuppression without modifications for COVID-19 prophylaxis.
  • Defer routine surveillance biopsies in patients with stable allograft function.
  • Minimize social interactions after transplantation.

In addition, the Toronto group(11) recently outlined a number of considerations likely to increase the chance of a positive outcome after lung transplantation in recipients previously infected with Covid-19, including:

  • an age limit of 65 years
  • patient should have only single organ dysfunction
  • allow sufficient time for lung recovery before considering transplantation (at least four to six weeks after initial clinical signs of respiratory failure)
  • radiological evidence of irreversible lung disease
  • the patient should be awake and able to discuss transplantation and its impact on quality of later life in terms of long-term immunosuppression therapy
  • patient should be able to participate in physical rehabilitation while on the waiting list
  • no notable comorbidities
  • recent negative SARS-CoV-2 PCR result, or infectivity assays using deep respiratory tract samples showing absence of viable virus


10. Guidance from the ISHLT re. SARS CoV-2 pandemic, documents/ SARS- CoV- 2_- Guidance- for- Cardiothoracic- Transplant-and-VAD-centers.pdf (2020, accessed 20 May 2020) (no abstract available)

11. Cypel M, Keshavjee S. When to consider lung transplantation for COVID-19. Lancet – Respiratory Med. Oct; 8(10): 944–946 (no abstract available)

XVIVO Insights PB-2020-10-28