Follow-Up Care after Adult Lung Transplantation: Summary of an Evidence-Based Clinical Practice Guideline for German-Speaking Countries

Lung transplantation (LTx) is a life-saving intervention for end-stage lung disease, yet long-term outcomes remain inferior compared to other solid organ transplants. No evidence-based national or international guidelines for post-transplant follow-up care existed prior to this work. This guideline aims to provide treating physicians with structured, evidence-based recommendations for follow-up care after LTx in adult patients. The guideline was developed with a multidisciplinary guideline group according to the guidance of the Association of the Scientific Medical Societies in Germany manual for evidence- and consensus-based guidelines. A systematic literature search was conducted across MEDLINE, Cochrane, Epistemonikos, and CINAHL databases through September 2024, focusing on randomized controlled trials and systematic reviews. Evidence quality was assessed using the GRADE framework and the Oxford Centre for Evidence-Based Medicine (CEBM) 2011 criteria. Consensus was established through structured consensus conferences, with recommendation strength classified as strong ("We recommend"), conditional ("We suggest"), or open ("may or may not"). Twelve evidence-based recommendations were developed, spanning five clinical domains: immunosuppression, infections, chronic lung allograft dysfunction (CLAD), and bone health. Tacrolimus was recommended over ciclosporin as the preferred calcineurin inhibitor, based on moderate-quality evidence demonstrating a significantly lower incidence of CLAD across four randomized controlled trials. Trimethoprim-sulfamethoxazole prophylaxis against Pneumocystis jirovecii and extended valganciclovir prophylaxis for cytomegalovirus-seropositive recipients were recommended. For CLAD, azithromycin was strongly recommended as a therapeutic trial to assess reversibility of graft dysfunction. Regarding bone health, daily calcium and vitamin D supplementation were strongly recommended for all recipients, with bisphosphonates, denosumab, or teriparatide indicated in those with osteopenia or manifest osteoporosis. This guideline provides the first structured, evidence-based framework for follow-up care after LTx in German-speaking countries. Tacrolimus-based triple immunosuppression, targeted infection prophylaxis, CLAD prevention, and systematic bone protection represent the cornerstones of post-transplant care. The guideline will remain valid until July 2030.