Lung transplant in Italy: State of art, needs and perspectives

Lung transplant is a surgical option for end stage lung diseases and remains the only effective treatment of selected patients. In the last 25 years we have seen an evolution in different fields of lung transplant management: indications and timing have been well defined, the choice of procedure better studied, immunosuppressive therapy has changed with an increasing number of drugs with advantages and side effects better defined. However there are many limitations in donor and recipient clinical management and a delicate balance between immunosuppression and infective diseases. The main limitation is represented by the shortage of suitable organs. In the last years, lung procurement has progressively changed in the clinical arena and different strategies aiming to increase the number of usable donor lungs have been reported. Many efforts have been employed to improve management of donor during donation with protective ventilation and careful fluid management and to treat marginal or even initially rejected grafts ex-vivo. Ex-vivo lung perfusion is a novel technique to maintain, evaluate and recondition lung grafts. It can be considered a real revolution in the field of LTx. Some transplant centers use lung grafts coming from donors with cardiac arrest after brain death. Moreover the recipient can be treated with Extracorporeal Membrane Oxygenation or with other gas exchange devices to allow an emergency allocation of organs. Finally one of the most important topics in lung transplant management is the role of viral infections in chronic lung allograft dysfunction (chronic rejection) and in acute rejection. Although most respiratory viral infections cause self-limited upper respiratory diseases, lung transplant recipients are particularly prone to develop complications. This review has the aim to explore the state of art of lung transplant in Italy showing lights and shadows, needs and perspectives.