[Chronic respiratory insufficiency: the role of lung transplantation]

Lung transplantation has been established as an appropriate ultimate treatment strategy in end-stage lung disease, when all conventional therapeutic options have been exhausted. Acute and potentially reversible lung diseases (ARDS, pneumonia) and malignancy (broncho-alveolar carcinoma) are not established indications. Retrospective analyses on the natural course of the disease and new medical treatment options have led to fewer transplantations in recipients with emphysema and idiopathic pulmonary hypertension. In end-stage cystic fibrosis and patients with idiopathic pulmonary fibrosis, alternative treatment options are currently not available and lung transplantation is indicated. The available guidelines for candidate selection should be followed. Internationally, there is a trend towards a benefit-orientated allocation of organs. Recommendations for candidate selection, surgical innovations and, especially, the improved long-term follow-up have led to improved results in the last two decades. Long-term results are, however, still unsatisfactory in comparison to liver and kidney transplantations. The main obstacles to long-term survival and causes of death are chronic allograft dysfunction (bronchiolitis obliterans syndrome, BOS) and infections. In the future, the pathogenesis and treatment options for these two entities should be clarified. A further essential task is to increase the donor pool in the future because the current waiting list mortality is approximately 20 %.