Lung Transplantation-Related Pathology

Updated: Jun 06, 2019
  • Author: Aliya N Husain, MBBS, MD; Chief Editor: Philip T Cagle, MD  more...
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Lung transplantation–related pathology encompasses a spectrum of disorders that include, but are not limited to, indications for lung transplantation (seen in explanted lungs), surgical complications (airway anastomotic and vascular complications), ischemia-reperfusion injury, rejection (acute and chronic), infections, and posttransplantation lymphoproliferative disorders (PTLDs).

Over the last few decades, lung transplantation has become an accepted modality of treatment for many end-stage lung diseases. With greater experience and analysis of significant numbers of cases, lung transplant recipients are living longer, and follow-up regimens are becoming streamlined. Thus, a comprehensive understanding of lung transplantation–related pathology is necessary for both tertiary care pathologists dealing with highly specialized lung transplantation teams and a much larger spectrum of healthcare providers who may be involved in the care of lung transplant recipients or candidates for lung transplantation.

Clinical features of lung transplantation–related pathology can range from an absence of symptoms to signs and symptoms of respiratory distress and/or infection and are not detailed in this article. Of note, clinical findings do not play a role in the pathologic grading of rejection.



The Registry of the International Society for Heart and Lung Transplantation (ISHLT) monitors and reports statistics on clinical lung transplantation. Data accrued between through June 30, 2017 show a total of 67,260 lung transplantations (64,803 in adults; 2,436 in children) from centers around the world, [1, 2]  whereas between 1989 and 2009, there were a total of 32,652 reported globally to the ISHLT, and in 2010, 3,519 lung transplantation procedures were reported. [3]

In the ISLHT 2018 report, lung transplantation–related pathology between 2004 and 2017, specifically acute rejection, was reported to affect a little over 30% of lung transplant recipients within the first postoperative year. [1, 2]

The main indications for single-lung transplantation, as reported by ISHLT 2018, include the following:

Bilateral lung transplantation is indicated for CF (99.5%), A1ATD (94.0%), followed by ILD-not IIP (80.6%), COPD (78.6%)  and IIP (66.0%). [1, 2]



The etiology of lung transplantation–related pathology is almost always immune-mediated. The transplantation of a ”foreign” organ, despite meticulous matching for donor-recipient compatibility, leads to a complex adaptive and innate immune system–mediated injury. Although aimed at protecting the host from infection, in the context of transplantation, this injury leads to allograft rejection. Such chronic injury is usually mediated by anti–human leukocyte antigen antibodies.

Although advances in tissue typing and cross-match testing have helped to deter severe transplant rejection, rejection may result from direct cellular attack (cellular rejection) or be mediated by antibodies (humoral rejection). These are discussed under the "Microscopic Findings" section.


Gross Findings

A quick intraoperative gross examination of the lung allograft may reveal previously unrecognized lesions, the nature of which could be addressed with frozen section analysis. Although rare, pulmonary embolism, infections, or neoplasms in the allograft may be diagnosed in this manner, which would affect the decision to use the donor lung.

Explanted lungs should be fixed in formalin (preferably by inflating through the main bronchus) for 8-12 hours and sliced at 1-cm intervals. The cut surface shows the characteristic findings of the disease for which lung transplantation was indicated.

Emphysema is end stage and generalized by the time the patient needs transplantation. Patchy fibrosis with greater involvement of the lower lobes and subpleural regions is readily apparent in idiopathic pulmonary fibrosis. In cystic fibrosis, the dilated bronchi are usually plugged by yellow-green mucopurulent material. The largest pulmonary arteries have small yellow atherosclerotic plaques in pulmonary arterial hypertension.


Microscopic Findings

In the explanted lung, the classic findings of the primary disease are readily apparent; in addition, there may be superimposed foci of acute inflammation, organizing pneumonia, and mucostasis.

In the transplanted lung, material for histologic evaluation is obtained via transbronchial biopsy and is analyzed after formalin fixation and paraffin processing. Tissue is obtained either as part of surveillance protocols or as clinically indicated by the new onset of symptoms.

This section describes microscopic findings of the following lung transplantation–related pathologies:

  • Lung allograft rejection

  • Infection

  • Posttransplant lymphoproliferative disease (PTLD)

Lung allograft rejection

The incidence of acute rejection is low with current immunosuppressive regimens, but chronic rejection remains the main complication that limits long-term survival. [1, 2] The International Society for Heart and Lung Transplantation (ISHLT) grading of lung transplant rejection was updated in 1996 [4] and revised in 2007 [5] (see Table 1). Grades B and C are simplified in the latter; however, many clinicians and pathologists still use the former system because it offers more information on which treatment decisions can be based.

In 2018, the ISHLT proposed a grading system for lung posttransplantation airway complications in adults and children that includes ischemia and necrosis (I), dehiscense (D), stenosis (S), and malacia (M). [6]  These categories are further subdivided by location (all) and extent (all but malacia). [6]  (See Table 2, below.)

Table 1. ISHLT Grading of Lung Transplant Rejection—1996 and 2007. (Open Table in a new window)



A. Acute Rejection

A. Acute Rejection

A0 - Normal

A1 - Minimal

A2 - Mild

A3 - Moderate

A4 - Severe

Grade 0 - None

Grade 1 - Minimal

Grade 2 - Mild

Grade 3 - Moderate

Grade 4 - Severe

B. Airway Inflammation

B. Airway Inflammation

BX - Inadequate sampling

B0 - None

B1 - Minimal

B2 - Mild

B3 - Moderate

B4 - Severe

Grade 0 - None

Grade 1R - Low grade*

Grade 2R - High grade*

Grade X - Ungradeable

C. Chronic Airway Rejection - Bronchiolitis obliterans

C. Chronic Airway Rejection - Obliterative bronchiolitis

a. Active

b. Inactive

0 - Absent

1 - Present

D. Chronic Vascular Rejection – Accelerated graft vascular sclerosis

D. Chronic Vascular Rejection – Accelerated graft vascular sclerosis

*”R" denotes revised grade to avoid confusion with the 1996 scheme.

Table 2. 2018 ISHLT Proposed Grading System for Lung Posttransplantation Airway Complications [6] (Open Table in a new window)




Ischemia and Necrosis (I)

a. Perianastomotic: Within 1 cm of the anastomosis

a. < 50% circumferential ischemia

b. Extends 41 cm from the anastomosis to the major airways (bronchus intermedius and distal left main stem)

b. >50%-100% of circumferential ischemia

c. Extends 41 cm from the anastomosis into the lobar or segmental airways

c. < 50% circumferential necrosis


d. >50%-100% of circumferential necrosis

Dehiscense (D)

a. Cartilaginous

a. 0%-25% of circumference

b. Membranous

b. >25%-50% of circumference

c. Both

c. >50%-75% of circumference


d. >75% of circumference

Stenosis (S)

a. Anastomotic

a. 0%-25% reduction in cross-sectional area

b. Anastomotic plus lobar/segmental

b. 25%-50% reduction in cross-sectional area

c. Lobar/segmental only

c. 50% to < 100% reduction in cross-sectional area


d. 100% distribution

Malacia (M)

a. Perianastomotic: Within 1 cm of the anastomosis


b. Diffuse: Involves the anastomosis and extends beyond 1 cm


Given the patchy nature of rejection, a consensus statement by the Lung Rejection Study Group (LRSG) recommends five fragments of well-expanded alveolated lung (with bronchioles and >100 alveolar spaces) be examined. [4] This may require more than five transbronchial biopsies, especially to recognize features of bronchiolitis obliterans (BO). Specimens may be gently agitated in formalin to inflate the fragments but require sensitive handling to avoid crush artifacts.

Histologic examination should include sections from three levels of the paraffin block for hematoxylin and eosin (H&E) staining. Connective-tissue stains may help evaluate any submucosal fibrosis. Silver stains can be performed for fungi. Immunohistochemical stain for cytomegalovirus (CMV) is very helpful and strongly recommended. Concomitant bronchoalveolar lavage (BAL) fluid may be analyzed to exclude infection, but it plays no role in the diagnosis of rejection.

If the biopsy samples contain diagnostic material but do not meet the minimum assessable criteria, grading should be carried out as usual, with a comment describing the number of lung fragments and emphasis that the material may not be representative of the overall allograft. Similarly, if no alveolated lung or no airway is present, the type of rejection should be indicated by the appropriate letter, suffixed by an "X" (see below). Biopsies taken for rejection surveillance should always be evaluated for histopathologic features indicative of infection, aspiration, organizing pneumonia, recurrent disease (eg, sarcoidosis), and PTLD.

Acute rejection

Acute rejection may occur at any time (days to years) following transplantation, but it is primarily seen between 2 and 9 months. The diagnosis is based on the presence of perivascular or airway inflammatory infiltrates that are composed mainly of activated lymphocytes but also contain few eosinophils, neutrophils, and plasma cells. The intensity and the distribution of the infiltrate form the basis of the histologic grade. With multiple foci of rejection, the grade reflects the most advanced pattern of rejection rather than the predominant or average pattern.

It is imperative to note evidence of aspiration (see image below) or concomitant infection, because these may precipitate rejection. Clinical findings play no role in the histopathologic grading of lung transplant rejection.

Lung transplantation-related pathology. Intraalveo Lung transplantation-related pathology. Intraalveolar multinucleated giant cell indicates microaspiration in this posttransplant transbronchial biopsy specimen (hematoxylin and eosin [H&E], 200x)

Acute cellular rejection, grade A

Perivascular inflammation forms the basis of grade A acute cellular rejection. The cellular components are the same in each of the following grades, which are determined by the extent of the inflammatory infiltrate:

  • Grade AX: No alveolated lung tissue or no arteriole or venule, precluding determination of the presence or absence of perivascular infiltrates

  • Grade A0 (no acute rejection): Normal pulmonary parenchyma without perivascular inflammation

  • Grade A1 (minimal acute rejection): Scattered perivascular infiltrates forming an incomplete or a two- or three-cell–layer–thick cuff (see the following image); rare eosinophils may be seen; endothelialitis is usually absent

    Lung transplantation-related pathology. This image Lung transplantation-related pathology. This image depicts minimal acute cellular rejection with incomplete perivascular cuff of inflammatory cells (grade A1) (hematoxylin and eosin [H&E], 200x).


  • Grade A2 (mild acute rejection): More frequent perivascular infiltrates (may be densely compacted or loose) consisting of round lymphocytes, activated lymphocytes, plasmacytoid lymphocytes, and macrophages (see the image below); eosinophils and endothelialitis may be present

    Lung transplantation-related pathology. This image Lung transplantation-related pathology. This image shows mild acute perivascular rejection with a thick complete cuff around a blood vessel (grade A2) (hematoxylin and eosin [H&E], 200x).


  • Grade A3 (moderate acute rejection): Dense perivascular mononuclear cell infiltrates with frequent foci of endothelialitis and extension into alveolar walls (see the following image); eosinophils and neutrophils are frequently present

    Lung transplantation-related pathology. Moderate a Lung transplantation-related pathology. Moderate acute perivascular rejection is revealed: The inflammation extends into adjacent alveolar walls and is accompanied by fibrinous exudates (grade A3) (hematoxylin and eosin [H&E], 200x).


  • Grade A4 (severe acute rejection): Diffuse perivascular, interstitial and alveolar infiltrates of mononuclear inflammatory cells; prominent pneumocyte damage and endothelialitis; intraalveolar necrotic epithelial cells, hyaline membranes, hemorrhage, and neutrophils may be seen

Acute cellular rejection, grade B

Grade B cellular rejection (lymphocytic bronchiolitis in the rejection classification) was described in the 1996 grading system update according to a scale of B0 to B4, (see Table 1, above) with B1 being treated only if accompanied by clinical symptoms of rejection, and B2 and above being treated regardless of symptoms. The 2006 revision of the B grades collapsed the four previous grades into two and retained B0 (no airway inflammation) and BX (ungradable). Airway inflammation may be present in the absence of perivascular infiltrates.

Grade B infiltrates represent a clinically important type of acute rejection as they have been shown to be a very strong risk factor for chronic rejection, necessitating their identification in allograft biopsy samples. Thus, many clinicians and pathologists prefer to use the 1996 grading system, which can be easily translated to the 2007 grading system (but not vice versa), if needed, for comparison.

  • Grade BX: Ungradable because of insufficient sample, artifact, infection, etc

  • Grade B0: No evidence of airway inflammation

  • Grade B1 (B1R) (minimal acute airway rejection): Few activated lymphocytes and plasma cells within the submucosa of the bronchioles (see the image below); rare eosinophils may be present; epithelial damage or intraepithelial lymphocytes are not seen

    Lung transplantation-related pathology. Note the m Lung transplantation-related pathology. Note the minimal acute airway rejection shown: There is focal inflammation in the submucosa (grade B1) (hematoxylin and eosin [H&E], 200x).


  • Grade B2 (B1R) (mild acute airway rejection): Bandlike infiltrate of activated, larger mononuclear cells in the submucosa (see the following image); more eosinophils, few neutrophils and plasma cells are present

    Lung transplantation-related pathology. This image Lung transplantation-related pathology. This image demonstrates mild acute airway rejection: There is a bandlike infiltrate in the submucosa (grade B2) (hematoxylin and eosin [H&E], 200x).
  • Grade B3 (B2R): The infiltrate extends from the submucosa into the epithelium but without epithelial damage (see the image below)

    Lung transplantation-related pathology. Moderate a Lung transplantation-related pathology. Moderate acute airway rejection is revealed: The inflammatory infiltrate extends into the overlying epithelium (grade B3) (hematoxylin and eosin [H&E], 200x).
  • Grade B4 (B2R): Epithelial damage (necrosis and metaplasia) and numerous intraepithelial lymphocytes are seen in addition to the B3 findings; this is rare with current immunosuppression regimens

NOTE: Bronchial-associated lymphoid tissue is often present and should not be interpreted as rejection (see image below).

Lung transplantation-related pathology. This image Lung transplantation-related pathology. This image shows bronchial-associated lymphoid tissue (BALT): A collection of small mature lymphocytes is present which is associated with pigment. Although no airway is seen in this figure, the morphologic appearance is not that of rejection (hematoxylin and eosin [H&E], 100x).

Antibody-mediated rejection

Antibody-mediated rejection, also called humoral or hyperacute rejection, is not included in the ISHLT classification owing to the scarcity of reports in the literature. There is no consensus on its recognition and diagnosis by either histopathologic or immunologic methods, nor on its significance and treatment.

Antibody-mediated rejection is characterized by the activation of inflammatory pathways along with the complement and coagulation cascades due to the binding of preformed antibody to endothelial cells. Progressive respiratory failure within minutes to hours after transplantation suggests antibody-mediated rejection. It is also thought to occur weeks or months after transplantation upon development of serum antibodies. Histologic evaluation reveals diffuse alveolar damage (DAD), fibrin thrombi, vasculitis, intraalveolar hemorrhage, and interstitial neutrophilia.

Chronic rejection

Chronic rejection usually occurs after 1 year posttransplantation but may be seen as early as within a few weeks. It is the most significant complication limiting long-term survival, affecting up to 50% of patients at 3 years posttransplantation. A previous episode of acute rejection is the most well-recognized risk factor.

Persistent significant decreases on lung function tests are the most reliable method to diagnose chronic rejection (clinically termed bronchiolitis obliterans syndrome). It manifests pathologically as BO, a chronic, progressive fibroinflammatory occlusion of small airways.

The pathogenic mechanism of chronic rejection is poorly understood, but it is thought to result from the monocyte/macrophage system with the airway epithelium, with upregulation of major histocompatibility complex (MHC) antigens, co-stimulatory molecules, and adhesion molecules, leading to an outpouring of inflammatory and fibroproliferative mediators. Chronic rejection should be suspected with an insidious onset of generalized symptoms, including cough and dyspnea with a progressive decline on pulmonary function tests.

Chronic airway rejection, obliterative bronchiolitis (grade C)

Although often difficult to diagnose on a transbronchial biopsy, BO is the characteristic histologic feature of grade C chronic rejection. In the early phase, the fibrosis is loose and often contains mononuclear inflammatory cells. Later, dense eosinophilic fibrosis is present in the bronchiolar submucosa, resulting in luminal occlusion. Destruction of smooth muscle of the airway wall may be present. Distal airspaces often reveal mucostasis with foamy histiocytes and lipoid pneumonia, which may be a histologic clue when BO is not seen in biopsy material.

Transbronchial biopsies are insufficiently sensitive for the detection of obliterative bronchiolitis, and a diagnosis of BO may require a wedge biopsy. Many clinicians want to know if the fibrosis contains inflammatory cells so that they can be targeted by appropriate treatment; thus, the 1996 grading is preferred in this setting.

  • C0: No BO seen

  • Ca (C1R): Asymmetric or concentric submucosal fibrosis causing partial or complete airway obstruction with inflammation (see image below)

    Lung transplantation-related pathology. Bronchioli Lung transplantation-related pathology. Bronchiolitis obliterans (chronic rejection) is revealed: The patient underwent retransplantation for chronic rejection, which is seen here as eccentric fibrosis partially occluding the airway lumen. Note the presence of scant inflammatory cells and plump fibroblasts in the lesion (hematoxylin and eosin [H&E], 100x).
  • Cb (C1R): Asymmetric or concentric submucosal fibrosis causing partial or complete airway obstruction without inflammation

Chronic vascular rejection (grade D)

Chronic vascular rejection (grade D rejection) is characterized by fibrointimal thickening of arteries and veins, with or without inflammatory infiltrates. Chronic vascular rejection is not diagnosed with transbronchial biopsies. Overall, grade D rejection is rare and has not been reported to cause significant allograft dysfunction. It is most often seen in the setting of BO.


Because of immunosuppressant therapy, transplant recipients are at an increased risk for both common and opportunistic infections. Bacterial infections tend to occur in the first month posttransplantation, with viral and fungal infections usually following within the first 3-6 months. Lung allograft infection is usually diagnosed based on clinical signs and symptoms, microbiologic cultures, and serum viral testing, but only occasionally with transbronchial biopsy.

Bacterial infection

Histologically, the presence of neutrophils in airway epithelium (see the image below) raises the differential of bacterial infection versus grade B cellular rejection. Similar to other immunocompromised situations, gram-negative infections in transplant recipients may not elicit significant inflammatory responses. Bacterial cultures are prudent in light of clinical suspicion. Mycobacterial infection is very rare. It may cause granulomatous inflammation in the lung allograft recipient and can result from either Mycobacterium tuberculosis or atypical acid-fast organisms.

Lung transplantation-related pathology. This image Lung transplantation-related pathology. This image demonstrates bacterial infection: The presence of mostly neutrophils in both the submucosa and mucosa is most suggestive of an infection (hematoxylin and eosin [H&E], 200x).

Viral infection

CMV infection can be diagnosed on H&E sections; however, immunohistochemistry for CMV antigens allows for earlier detection and treatment, especially in the first posttransplantation year (see the following image). Histologically, CMV is characterized by enlarged cells (cytomegaly) with single large basophilic intranuclear inclusions and a clear halo. Viral infections may also be diagnosed with serologic techniques or culture. Matching the CMV status (donor and recipient), widespread use of prophylaxis, and the monitoring of viral load with polymerase chain reaction (PCR) have significantly reduced the incidence of CMV pneumonitis in transplant recipients. Viral infection places patients at a higher risk of acute and chronic rejection and death.

Lung transplantation-related pathology. The image Lung transplantation-related pathology. The image reveals cytomegalovirus (CMV) infection by immunohistochemical (IHC) staining: Both enlarged nuclei and normal-sized infected nuclei stain positively. This feature is helpful when viral inclusions are not readily apparent on hematoxylin and eosin (H&E) stain. (IHC stain using antibody against immediate early antigen, 200x)

Fungal infection

Silver stains help highlight fungal yeast/hyphae. Culprit organisms include Candida species, Aspergillus, and Mucor. Owing to routine prophylaxis, Pneumocystis infection is extremely rare.

Posttransplantation lymphoproliferative disease

PTLD is an EBV-driven condition that has been described in all transplant populations and is a particular problem in lung allograft recipients, in whom it usually involves the allograft itself, as well as nodal and extranodal sites. Improved immunosuppression modalities have decreased the overall incidence of PTLD; however, the incidence is reported to vary between 1% and 11.7%. [7, 8]

Histologically, PTLD may range from a collection of cytologically benign polyclonal lymphocytes to a monoclonal proliferation with features akin to a high-grade B-cell lymphoma (see the image below). PTLD confined to the allograft has a better overall outcome than disseminated disease. [9]

Lung transplantation-related pathology. This image Lung transplantation-related pathology. This image demonstrates posttransplant lymphoproliferative disorder (PTLD): There is a diffuse infiltrate of atypical lymphoid cells, obliterating the lung architecture, with a foci of necrosis, as would be seen in a large-cell lymphoma (hematoxylin and eosin [H&E], 200x).




In most cases, the diagnosis of acute and chronic rejection of a lung transplant is made on hematoxylin and eosin (H&E)-stained sections.

The role of C4d immunostaining for antibody-mediated rejection in the lung remains controversial. [10]

Immunostaining for lymphocyte markers (B- and T-cells) and in situ hybridization for Ebstein-Barr virus (EBV) mRNA (EBER) and cytomegalovirus (CMV) may be performed as appropriate.


Prognosis and Predictive Factors

The presence of elevated epithelial and erythrocyte microvesicles in bronchoalveolar lavage fluid are associated with outcome in chronic lung allograft dysfunction, [11] and donor bronchial hypoxia appears to be a driver for posttransplantation airway complications. [12]

According to the International Society for Heart and Lung Transplantation (ISHLT) 2018 report, risk factors for 1-year mortality are related to the indication for transplantation. [1, 2] Poor prognostic factors include older recipient  and donor ages, recipient's creatinine and bilirubin levels, lower transplant-center volume,recipient's lower predicted forced vital capacity, and the ischemic time. [1, 2]

The top five causes of death for lung transplant alone within 1 year posttransplantation were the following [1, 2] :

  • Graft failure: 24.0% at 30 days, 16.5% between 31 days and 1 year
  • Infection: 18.7% at 30 days, 36.4% between 31 days and 1 year
  • Multiorgan failure: 12.6% at 30 days, 112.1% between 31 days and 1 year
  • Cardiovascular: 12% at 30 days, 5.5% between 31 days and 1 year
  • Technical: 11.9% at 30 days, 3.5% between 31 days and 1 year

Questions & Answers


What is lung transplantation-related pathology?

What is the prevalence of lung transplantation-related pathology?

What are the indications for lung transplantation?

What causes lung transplantation-related pathology?

Which gross findings are characteristic of lung transplantation-related pathology?

What is included in the histologic exam to evaluate lung transplant rejection?

How is tissue obtained for histologic evaluation of lung transplantation-related pathology?

How is lung transplant rejection graded?

How is acute lung transplant rejection diagnosed?

Which microscopic findings are characteristic of acute cellular lung transplantation rejection, grade A?

Which microscopic findings are characteristic of acute cellular lung transplantation rejection, grade B?

Which microscopic findings are characteristic of antibody-mediated lung transplantation rejection?

Which microscopic findings are characteristic of chronic lung transplantation rejection?

Which microscopic findings are characteristic of lung transplantation rejection, grade C?

Which microscopic findings are characteristic of lung transplantation rejection, grade D?

How is lung allograft infection diagnosed?

Which histologic findings are characteristic of lung allograft bacterial infection?

Which histologic findings are characteristic of lung allograft viral infection?

Which histologic findings are characteristic of lung allograft fungal infection?

Which histologic findings are characteristic of lung transplantation-related PTLD?

What is the role of immunohistochemistry in the diagnosis of lung transplantation-related pathology?

What are the risk factors for lung transplantation mortality?

What are the most common causes of lung transplantation mortality?