From guideline to practice: Operationalizing telomere length testing in ILD and lung transplantation

The recent International Society for Heart and Lung Transplantation (ISHLT) consensus statement on short telomere syndrome, while focused on lung transplant evaluation, has implications that extend beyond the transplant setting. By formalizing the role of telomere length (TL) testing in transplant care, the consensus has practical implications for clinicians caring for the broader interstitial lung disease (ILD) population. Short telomeres are the most common inherited risk factors for fibrotic ILD and are associated with disease progression, extrapulmonary complications, and increased susceptibility to treatment-related toxicities, including those relevant to immunosuppression and transplant outcomes. As such, TL testing has the potential to inform key clinical decisions, including risk stratification, timing of referral, and peri-transplant planning. Despite this promise, implementation of TL testing in routine practice is limited by the absence of standardized clinical pathways. In this perspective, we do not seek to extend the consensus beyond its stated scope; rather we highlight the practical realities the consensus creates for clinicians caring for patients across the ILD-to-transplant continuum, including who should be tested, when testing should occur, and how results should be interpreted and integrated with genetic and clinical data. We outline major implementation challenges and propose a research agenda to develop intentional, structured, and evidence-based strategies to support the integration of TL testing into ILD and transplant care. TL testing now stands at a critical inflection point; ensuring its responsible, scalable, and equitable implementation will be essential to realizing its potential to improve outcomes across the ILD-to-transplant continuum.