Indications for pediatric lung transplantation in 2025: A new era

The year 2025 marks an important landmark: almost 40 years since the first pediatric lung transplant (LTX), over 3-5 years since the availability of elexacaftor/tezacaftor/ivacaftor in several countries, and 5-10 years since striking shifts were reported in the diagnoses that accounted for pediatric LTX. We review historic indications for pediatric LTX, highlighting shifts in these over time, and analyze data from the ISHLT International Thoracic Organ Transplant Registry, United Network of Organ Sharing, Canadian Cystic Fibrosis (CF) Registry, and other databases up to the present day. Currently, pediatric CF-related LTX cases are at record lows in many countries. Non-retransplant bronchiolitis obliterans seems to be on the rise as a transplant indication in pediatrics, which is particularly true in the younger age group per ISHLT data. Childhood interstitial lung disease is increasing as an indication, especially in North America. Idiopathic pulmonary arterial hypertension (IPAH) and pulmonary hypertension as a whole now account for record highs as indications for pediatric LTX around the world, with IPAH alone now accounting for nearly 20% of pediatric LTX in the United States, for instance. This information will help guide future international pediatric thoracic transplant consensus guidelines around candidate selection and optimization, placing more emphasis on non-CF considerations.