European society for organ transplantation clinical practice guideline on prevention and treatment of chronic lung allograft dysfunction
In brief
Guideline favors tacrolimus and azithromycin to lower chronic lung graft dysfunction risk
Chronic lung allograft dysfunction affects up to half of lung transplant recipients within 5 years. The European guideline favors tacrolimus over cyclosporine, mycophenolate or azathioprine, and azithromycin for prevention; montelukast can be considered for early bronchiolitis obliterans syndrome. Evidence remains inconclusive for several other treatments, and antifibrotics are not supported for this syndrome.
- Journal
- Transplant international : official journal of the European Society for Organ Transplantation (Q1)
- Published
- 18 September 2026
- Study design
- Practice guideline / consensus
- Evidence level
- Level 1, High (CEBM 1c)
- Authors
- Saskia Bos, Merel Hellemons, Kavita Dave, Maarten F M Engel, Are Holm, Letizia Morlacchi, et al.
- PMID
- 42827470
- DOI
- 10.3389/ti.2026.16959
Why clinicians should know about it
- Picked for Pulmonary and Respiratory Medicine (top studies of the week, 4 October 2026): High-quality evidence in a top journal
Abstract
Chronic lung allograft dysfunction (CLAD) is the primary cause of late graft loss after lung transplantation, affecting up to half of lung transplant recipients within 5 years and presenting with heterogeneous phenotypes, most commonly bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome. Prevention and treatment of CLAD are challenging. This European Society for Organ Transplantation (ESOT) clinical practice guideline was developed by a multidisciplinary Task Force, including patient and allied healthcare representation, using systematic reviews and GRADE methodology. Eight key PICO questions addressing prevention and treatment of CLAD were evaluated. In terms of prevention, recommendations are in favor of using tacrolimus over cyclosporine, either mycophenolate or azathioprine, and azithromycin to reduce the risk of CLAD. Regarding treatment, montelukast could be considered in early-stage BOS. Current data are inconclusive in demonstrating benefits of anti-thymocyte globulin, alemtuzumab or extracorporeal photopheresis compared with standard of care, and do not support the use of antifibrotics in BOS. The Task Force emphasizes the urgent need for high-quality clinical trials and standardized care pathways in CLAD management.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.