Table 3.

High risk recipient characteristics

	Special considerations	Management
Advanced Age	Frailty and Functional status Cardiac and vascular disease Cognitive impairment	Intensive rehabilitation pre and post LTX, focus on nutrition Extensive workup Neurocognitive testing to identify early, alter immunosuppression, neuro rehab
HIV	Ensure viral suppression and optimal CD4 count Higher risk of post LTx infection Monitoring for interactions between HAART and CNI	Stable HAART regimen and ID evaluation pre LTX Collaboration with ID and pharmacy for close monitoring
Scleroderma	Digital ulcers Esophageal dysmotility GERD	Minimize pressors and decrease arterial lines, use CCB if needed Aspiration precautions, NPO and post pyloric feeds for 3 months Consider anti reflux surgery
CAD	Moderate CAD Severe CAD	Aggressive medical management in moderate disease Concomitant CABG or pre LTX PCI based on recipient factors (ability to tolerate surgery, ability to wait to complete DAPT pre transplant)
Critical illness	Non pulmonary organ dysfunction common High risk of infection/sepsis Deconditioning and debility Sedation and mentation Risk of thrombosis and bleeding	Multidisciplinary critical care team with routine evaluation for appropriate candidacy Establish clear expectations with patient and family given high chance of clinical worsening
HIV	Ensure viral suppression and optimal CD4 count Higher risk of post LTx infection Monitoring for interactions between HAART and CNI	Stable HAART regimen and ID evaluation pre LTX Collaboration with ID and pharmacy for close monitoring
High allosensitization	Longer wait list duration Increased risk of acute rejection (ACR and AMR) Increased risk for CLAD	List earlier anticipating higher wait list duration Surveillance with regular DSA and bronchoscopies Optimize immunosuppression post-transplant

Abbreviations: ACR acute cellular rejection, AMR antibody-mediated rejection, CABG coronary artery bypass grafting, CAD coronary artery disease, CCB calcium channel blocker, CLAD chronic lung allograft dysfunction, LTX lung transplant, CNI calcineurin inhibitor, DAPT dual anti-platelet therapy, DSA donor-specific antibodies, GERD gastroesophageal reflux disease, HAART highly active antiretroviral therapy, ID infectious disease, NPO nothing by mouth, PCI percutaneous intervention