Expert consensus on lung transplant evaluation in patients with respiratory failure due to virus-induced pulmonary injury_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 Thoracic Surgery Society of the Shanghai Medical Association , Thoracic Surgery Subcommittee of the Shanghai Medical Doctor Association , The National Alliance for Enhancing Clinical Competence in General Thoracic Surgery

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, Shanghai, 200433, P. R. China;

Corresponding author：

Thoracic Surgery Society of the Shanghai Medical Association, Email: chenthoracic@163.com

Keywords：

Viral pneumonia; lung transplantation; end-stage lung disease; assessment criteria; expert consensus

DOI：

10.7507/1007-4848.202505006

Video：

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Abstract Full text Figures/Tables Video References Cited by

Severe viral pneumonia caused by highly pathogenic viruses frequently leads to acute respiratory distress syndrome (ARDS) and may progress to irreversible pulmonary fibrosis and chronic respiratory failure. Lung transplantation has become a crucial therapeutic option for such end-stage lung injuries. However, due to the heterogeneous clinical course and lack of standardized assessment, identifying transplant timing and suitable candidates remains challenging. This multidisciplinary consensus, based on both international evidence and clinical experience, outlines key principles and structured recommendations for lung transplant evaluation in these patients. The framework addresses transplant indications, imaging and functional assessment of irreversibility, virologic control criteria, potential survival benefit, and postoperative recovery capacity. The consensus emphasizes initiating evaluation during the “window of opportunity”, when lung damage is irreversible, infection is controlled, and the patient remains clinically stable. Recommendations are graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide evidence-based decision-making and improve clinical implementation and transplant outcomes.

Citation： Thoracic Surgery Society of the Shanghai Medical Association, Thoracic Surgery Subcommittee of the Shanghai Medical Doctor Association, The National Alliance for Enhancing Clinical Competence in General Thoracic Surgery. Expert consensus on lung transplant evaluation in patients with respiratory failure due to virus-induced pulmonary injury. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(8): 1056-1062. doi: 10.7507/1007-4848.202505006 Copy

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2.	Leuschner G, Behr J. Acute exacerbation in interstitial lung disease. Front Med (Lausanne), 2017, 4: 176.
3.	Kondoh Y, Kataoka K, Ando M, et al. COVID-19 and acute exacerbation of interstitial lung disease. Respir Investig, 2021, 59(6): 675-678.
4.	Huang WJ, Tang XX. Virus infection induced pulmonary fibrosis. J Transl Med, 2021, 19(1): 496.
5.	Otto C, Huzly D, Kemna L, et al. Acute fibrinous and organizing pneumonia associated with influenza A/H1N1 pneumonia after lung transplantation. BMC Pulm Med, 2013, 13(1): 30.
6.	Wang Q, Pan S, Zhang S, et al. Lung transplantation in pulmonary fibrosis secondary to influenza A pneumonia. Ann Thorac Surg, 2019, 108(3): e233-e235.
7.	Kurihara C, Manerikar A, Querrey M, et al. Clinical characteristics and outcomes of patients with COVID-19–associated acute respiratory distress syndrome who underwent lung transplant. JAMA, 2022, 327(7): 652-661.
8.	Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014—an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant, 2015, 34(1): 1-15.
9.	Shah SA, Nwaru BI, Sheikh A, et al. Development and validation of a multivariable mortality risk prediction model for COPD in primary care. NPJ Prim Care Respir Med, 2022, 32(1): 21.
10.	Ley B, Ryerson CJ, Vittinghoff E, et al. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med, 2012, 156(10): 684-691.
11.	Lang C, Ritschl V, Augustin F, et al. Clinical relevance of lung transplantation for COVID-19 ARDS: a nationwide study. Eur Respir J, 2022, 60(6): 2102404.
12.	Han X, Fan Y, Alwalid O, et al. Fibrotic interstitial lung abnormalities at 1-year follow-up CT after severe COVID-19. Radiol, 2021, 301(3): E438-E440.
13.	Ali RMM, Ghonimy MBI. Post-COVID-19 pneumonia lung fibrosis: a worrisome sequelae in surviving patients. Egypt J Radiol Nucl Med, 2021, 52(1): 101.
14.	Zou JN, Sun L, Wang BR, et al. The characteristics and evolution of pulmonary fibrosis in COVID-19 patients as assessed by AI-assisted chest HRCT. PLoS One, 2021, 16(3): e0248957.
15.	Zhang D, Zhang C, Li X, et al. Thin-section computed tomography findings and longitudinal variations of the residual pulmonary sequelae after discharge in patients with COVID-19: a short-term follow-up study. Eur Radiol, 2021, 31(12): 7172-7183.
16.	Patrucco F, Curtoni A, Sidoti F, et al. Herpes virus infection in lung transplantation: diagnosis, treatment and prevention strategies. Viruses, 2023, 15(9): 2326.
17.	Marczin N, de Waal ECC, Hopkins PMA, et al. International consensus recommendations for anesthetic and intensive care management of lung transplantation. J Heart Lung Transplant, 2021, 40(11): 1327-1348.
18.	Green M. Management of Epstein-Barr virus-induced post-transplant lymphoproliferative disease in recipients of solid organ transplantation. Am J Transplant, 2001, 1(1): 103-108.
19.	Singer JP, Diamond JM, Gries CJ, et al. Frailty phenotypes, disability, and outcomes in adult candidates for lung transplantation. Am J Respir Crit Care Med, 2015, 192(5): 1325-1334.
20.	Schaenman JM, Diamond JM, Greenland JR, et al. Frailty and aging-associated syndromes in lung transplant candidates and recipients. Am J Transplant, 2021, 21(5): 2018-2024.

1. Liao KM, Chen YJ, Shen CW, et al. The influence of influenza virus infections in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis, 2022, 17: 2253-2261.
2. Leuschner G, Behr J. Acute exacerbation in interstitial lung disease. Front Med (Lausanne), 2017, 4: 176.
3. Kondoh Y, Kataoka K, Ando M, et al. COVID-19 and acute exacerbation of interstitial lung disease. Respir Investig, 2021, 59(6): 675-678.
4. Huang WJ, Tang XX. Virus infection induced pulmonary fibrosis. J Transl Med, 2021, 19(1): 496.
5. Otto C, Huzly D, Kemna L, et al. Acute fibrinous and organizing pneumonia associated with influenza A/H1N1 pneumonia after lung transplantation. BMC Pulm Med, 2013, 13(1): 30.
6. Wang Q, Pan S, Zhang S, et al. Lung transplantation in pulmonary fibrosis secondary to influenza A pneumonia. Ann Thorac Surg, 2019, 108(3): e233-e235.
7. Kurihara C, Manerikar A, Querrey M, et al. Clinical characteristics and outcomes of patients with COVID-19–associated acute respiratory distress syndrome who underwent lung transplant. JAMA, 2022, 327(7): 652-661.
8. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014—an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant, 2015, 34(1): 1-15.
9. Shah SA, Nwaru BI, Sheikh A, et al. Development and validation of a multivariable mortality risk prediction model for COPD in primary care. NPJ Prim Care Respir Med, 2022, 32(1): 21.
10. Ley B, Ryerson CJ, Vittinghoff E, et al. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med, 2012, 156(10): 684-691.
11. Lang C, Ritschl V, Augustin F, et al. Clinical relevance of lung transplantation for COVID-19 ARDS: a nationwide study. Eur Respir J, 2022, 60(6): 2102404.
12. Han X, Fan Y, Alwalid O, et al. Fibrotic interstitial lung abnormalities at 1-year follow-up CT after severe COVID-19. Radiol, 2021, 301(3): E438-E440.
13. Ali RMM, Ghonimy MBI. Post-COVID-19 pneumonia lung fibrosis: a worrisome sequelae in surviving patients. Egypt J Radiol Nucl Med, 2021, 52(1): 101.
14. Zou JN, Sun L, Wang BR, et al. The characteristics and evolution of pulmonary fibrosis in COVID-19 patients as assessed by AI-assisted chest HRCT. PLoS One, 2021, 16(3): e0248957.
15. Zhang D, Zhang C, Li X, et al. Thin-section computed tomography findings and longitudinal variations of the residual pulmonary sequelae after discharge in patients with COVID-19: a short-term follow-up study. Eur Radiol, 2021, 31(12): 7172-7183.
16. Patrucco F, Curtoni A, Sidoti F, et al. Herpes virus infection in lung transplantation: diagnosis, treatment and prevention strategies. Viruses, 2023, 15(9): 2326.
17. Marczin N, de Waal ECC, Hopkins PMA, et al. International consensus recommendations for anesthetic and intensive care management of lung transplantation. J Heart Lung Transplant, 2021, 40(11): 1327-1348.
18. Green M. Management of Epstein-Barr virus-induced post-transplant lymphoproliferative disease in recipients of solid organ transplantation. Am J Transplant, 2001, 1(1): 103-108.
19. Singer JP, Diamond JM, Gries CJ, et al. Frailty phenotypes, disability, and outcomes in adult candidates for lung transplantation. Am J Respir Crit Care Med, 2015, 192(5): 1325-1334.
20. Schaenman JM, Diamond JM, Greenland JR, et al. Frailty and aging-associated syndromes in lung transplant candidates and recipients. Am J Transplant, 2021, 21(5): 2018-2024.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Expert consensus on lung transplant evaluation in patients with respiratory failure due to virus-induced pulmonary injury

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