Lung Transplant Referral Guidelines

The purpose of these guidelines is to provide recommendations to the CF community regarding appropriate identification and timely referral of individuals with advanced CF lung disease to transplant centers.

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Summary
  • The Cystic Fibrosis Foundation assembled a multi-disciplinary committee that utilized PICO (population, intervention, control, outcome) methodology to guide systematic searches of the medical literature.
  • Twenty-one recommendations were ultimately included in the final guidelines, each with 100 percent agreement among committee members.

Lung Transplant Referral for Individuals With Cystic Fibrosis: Executive Summary

Ramos KJ, Smith PJ, McKone EF, Pilewski JM, et al. Lung transplant referral for individuals with cystic fibrosis: Cystic Fibrosis Foundation consensus guidelines. J Cyst Fibros. 2019 May;18(3):321-333. doi: 10.1016/j.jcf.2019.03.002. Epub 2019 Mar 27.

Purpose and Background

Despite improvements in life expectancy, pulmonary disease remains the major cause of morbidity and mortality for individuals with cystic fibrosis. Lung transplantation (lung transplant) therefore will continue to remain an important therapeutic option for individuals with advanced CF lung disease. However, a significant number of individuals with CF die each year without lung transplant referral.

Early referral for lung transplant increases the likelihood that an individual with CF will be deemed an appropriate candidate for lung transplant and ultimately undergo successful transplant. Early referral also allows modifiable barriers to transplant to be addressed proactively, thereby optimizing candidacy.

Conversely, late referral may result in missing the ideal “window” for transplantation, increasing the risks of waiting list mortality and severe post-transplant complications. The purpose of these guidelines is to provide recommendations to the CF community regarding appropriate identification and timely referral of individuals with advanced CF lung disease to transplant centers.

Methodology

The Cystic Fibrosis Foundation assembled a multi-disciplinary committee that utilized PICO (population, intervention, control, outcome) methodology to guide systematic searches of the medical literature. Additional information was gathered from a focus group of transplant recipients with CF and spouses of recipients. Draft recommendations were developed, voted on by the committee, and accepted if 80 percent of the committee agreed. Public comments were then solicited, leading to another round of revisions and voting by the committee. Twenty-one recommendations were ultimately included in the final guidelines, each with 100 percent agreement among committee members.

Recommendations

Recommendations Evaluation of the Evidence
1. The CF Foundation recommends routine clinician-led efforts to discuss disease trajectory and treatment options, including a discussion of lung transplantation. 100% Consensus
2. The CF Foundation recommends CF care team-initiated discussion regarding lung transplantation with all individuals with CF and a forced expiratory volume in one second (FEV1) < 50% predicted. 100% Consensus
3. The CF Foundation recommends the use of up-to-date CF-specific transplant resources to promote understanding of the transplant journey and to minimize misconceptions regarding outcomes. 100% Consensus
4. The CF Foundation recommends that CF clinicians develop relationships with peers at partnering transplant centers. 100% Consensus
5. The CF Foundation recommends that the individual's CF care team elicit and address CF-specific psychosocial and physical concerns about lung transplantation to facilitate transition to transplant. 100% Consensus
6. The CF Foundation recommends that modifiable barriers to lung transplantation be addressed preemptively to optimize transplant candidacy; however, unresolved barriers should not preclude referral. 100% Consensus
7. The CF Foundation recommends the CF and lung transplant care teams acknowledge and provide support for mental health concerns regarding the referral and evaluation process for transplant that are unique to individuals with CF. 100% Consensus
8. The CF Foundation recommends lung transplant evaluation, regardless of FEV1, when there are markers of shortened survival including: 6-minute walk test (6MWT) distance < 400 meters, hypoxemia (at rest or exertion), hypercarbia, or pulmonary hypertension. 100% Consensus
9. For individuals with CF who are 18 years of age and older, the CF Foundation recommends lung transplant referral no later than when:
  • FEV1 is < 50% predicted and rapidly declining (>20% relative decline within 12 months);
  • FEV1 is < 40% predicted with markers of shortened survival
  • FEV1 is < 30% predicted
100% Consensus
10. For individuals with CF who are under the age of 18 years, the CF Foundation recommends lung transplant referral no later than when:
  • FEV1 is < 50% predicted and rapidly declining (>20% relative decline within 12 months);
  • FEV1 is < 50% with markers of shortened survival
  • FEV1 is < 40% predicted
100% Consensus
11. For individuals with CF and an FEV1 <40% predicted, the CF Foundation recommends an annual 6MWT, assessment of need for supplemental oxygen, and venous blood gas to screen for markers of severe disease that may warrant transplant referral. 100% Consensus
12. For individuals with CF who are 18 years and older with FEV1 < 40% predicted, the CF Foundation recommends a baseline echocardiogram to screen for pulmonary hypertension. 100% Consensus
13. The CF Foundation recommends lung transplant referral for adults with CF with a body mass index (BMI) < 18 and FEV1 < 40% predicted while concurrently working to improve nutritional status. 100% Consensus
14. The CF Foundation recommends lung transplant referral for individuals with FEV1 < 40% predicted and > 2 exacerbations per year requiring intravenous (IV) antibiotics, or 1 exacerbation requiring positive pressure ventilation, regardless of FEV1. 100% Consensus
15. The CF Foundation recommends lung transplant referral for individuals with FEV1 < 40% predicted and massive hemoptysis (>240 mL) requiring intensive care unit (ICU) admission or bronchial artery embolization. 100% Consensus
16. The CF Foundation recommends lung transplant referral for individuals with FEV1 < 40% predicted and pneumothorax. 100% Consensus
17. For females with CF, especially those who are younger, the CF Foundation recommends special consideration for lung transplant referral even when other thresholds have not been met. 100% Consensus
18. For individuals with short stature (height <162 cm), the CF Foundation recommends special consideration for lung transplant referral even when other thresholds have not been met. 100% Consensus
19. The CF Foundation recommends CF clinician consultation with local and geographically distant lung transplant centers for individuals with microorganisms that may pose a risk for lung transplantation. 100% Consensus
20. Before determining that an individual is not a transplant candidate, the CF Foundation recommends consultation with at least two transplant centers, one of which should have experience addressing the individual's potential contraindications to transplantation. 100% Consensus
21. For transplant candidates, the CF Foundation recommends communication between the CF and lung transplant care teams at least every 6 months and with major clinical changes. 100% Consensus

Unanswered Questions

  • How do cystic fibrosis transmembrane conductance regulator modulators influence the course of advanced CF lung disease and will these medications eventually change the current consensus recommendations on the timing of referral for lung transplant?
  • Is there a role for more personalized risk “calculators” in determining the optimal time for referral or listing for lung transplant?
  • Once a patient has been referred to a transplant center, what factors should determine the timing of listing for transplant and how does this vary across transplant centers?
  • Are there additional CF-specific factors that should be included in the lung allocation score calculation?

Further Reading

Relevant manuscripts published after the original guidelines are listed below. These manuscripts have not been reviewed or endorsed by the guidelines committee.

  1. Lehr CJ, Skeans M, Dasenbrook EC, Fink A, et al. Effect of Including Important Clinical Variables on Accuracy of the Lung Allocation Score for Cystic Fibrosis and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2019 Oct 15;200(8):1013-1021. doi: 10.1164/rccm.201902-0252OC.
    Identifies predictors of mortality that are not included in the lung allocation score for individuals with CF listed for lung transplant. A 30 percent relative decline in FEV1 during the year prior to listing is associated with increased risk of death on the waiting list.
  2. Stanojevic S, Sykes J, Stephenson AL, Aaron SD, Whitmore GA. Development and External Validation of 1- and 2- year Mortality Prediction Models in Cystic Fibrosis. Eur Respir J. 2019 Sep 5;54(3). pii: 1900224. doi: 10.1183/13993003.00224-2019. Print 2019 Sep.
    Describes a validated predictive risk model for mortality in the CF population.
  3. O’Shea KM, O’Carroll OM, Carroll C, et al. Efficacy of elexacaftor/tezacaftor/ivacaftor in patients with cystic fibrosis and advanced lung disease. Eur Respir J. 2021 Feb 25;57(2):2003079.  doi: 10.1183/13993003.03079-2020.
  4. Asif H, Rahaghi FF, Ohsumi A, et al. Recommendations for Management of Nontuberculous Mycobacterial (NTM) in Lung Transplant Recipients: An International Delphi Study. Am J Respir Crit Care. Med 2021;203:A3945

This executive summary was prepared by:

Kathleen J. Ramos, MD, (University of Washington Medical Center), David M. Sayah, MD, PhD (David Geffen School of Medicine at UCLA)

The guidelines were published in May 2019, they were reviewed in July 2021 and it was determined that no update is needed at this time.

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Topics
Clinical Care Guidelines | Clinician Resources
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Lung Transplant Phases Guide Download (PDF)
Lung Transplant Referral Form Download (PDF)
Clinical Care Checklist for Advanced Cystic Fibrosis Lung Disease: a Guide for Physicians Download (PDF)
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