Controversies and emerging topics in lung transplantation

Lung transplantation provides a realistic hope of improved survival and enhanced quality of life. However, outcomes can be disappointing, meaning many decisions are highly controversial. Practice is largely based on expert opinion and there is a dearth of high-level evidence. Not surprisingly, this leads to centre-specific practices that may vary considerably in controversial areas. The aim of this review, therefore, is to explore some of those domains and present the available evidence. As the science of lung transplantation approaches its fifth decade, we are only now reaching a critical mass of clinicians and scientific researchers to enable adequately powered studies to assist in informing our approach to some of these controversies. KEY POINTS: Lung transplantation remains an art, combining experience with evidence. Clinicians need evidence to guide them on a myriad of questions, from candidate selection and listing, to organ donor acceptance, immunosuppression and chronic allograft dysfunction. Chronic lung allograft dysfunction pathogenesis deserves further detailed study. EDUCATIONAL AIMS: To illustrate the spectrum of controversial areas in lung transplantation including whom to list, which organs can be used and for whom, immune suppression and infection prophylaxis, and causes and phenotypes of chronic lung allograft dysfunction. To inspire clinicians to always ask questions and help collect the evidence we need to inform decision making.