With approximately 20,000 individuals in the United States living with a lung transplant, general pulmonologists are increasingly encountering posttransplant patients. However, many nontransplant providers report discomfort managing the unique challenges these patients present. Advanced practice providers (APPs)—including nurse practitioners and physician assistants/associates—increasingly bridge this gap.
Lung transplant recipients require nuanced, multidisciplinary care that extends beyond the capabilities of many general pulmonary practitioners. While general pulmonologists are encouraged to participate in longitudinal management—particularly for comorbidities and preventative care—the literature consistently underscores the challenges in identifying and managing transplant-specific complications such as rejection, infection, and allograft dysfunction.1,2
APPs are uniquely positioned to support the care of these patients’ complex cases. Their consistent presence during lung transplant services—where physicians often rotate—allows them to maintain continuity, deliver direct care, and educate both patients and medical professionals.
The expanding role of APPs
Inpatient settings: In hospital-based transplant programs, APPs often lead or support daily rounds, coordinate care with consulting specialties (eg, nephrology, infectious disease), and serve as the primary continuity providers. They play a pivotal role in evaluating trends in pulmonary function, identifying early signs of graft dysfunction, and managing immunosuppressive regimens. Their consistent clinical presence ensures proactive intervention and comprehensive discharge planning.
Outpatient clinics: APPs manage stable posttransplant patients in clinic settings, independently or alongside transplant pulmonologists. They monitor for signs of rejection or infection, titrate immunosuppressive medications, and conduct routine screening for corticosteroid-related complications (eg, osteoporosis, diabetes). They also facilitate essential surveillance testing, including pulmonary function tests (PFTs) and bronchoscopy schedules.
Community integration and telehealth: With many transplant recipients living far from specialized centers, APPs are increasingly extending their expertise through telehealth and regional outreach. They act as liaisons to local pulmonologists and primary care physicians, offering case reviews, consultative support, and guidance on when to escalate care back to the transplant center.
Leadership: APPs educate patients and families on posttransplant expectations, medication adherence, and lifestyle modifications. Within the clinical team, they mentor new staff, train rotating residents and fellows, and contribute to quality improvement initiatives. APPs often participate in protocol development and institutional guideline updates to standardize transplant care.
Care coordination: Posttransplant care requires meticulous coordination across multiple disciplines. APPs routinely collaborate with pharmacists, social workers, coordinators, and dietitians to optimize outcomes. Their role is essential in organizing follow-up appointments, managing transitions between inpatient and outpatient care, and ensuring timely interventions for complications.
Core clinical principles: A head-to-toe overview
Lung transplant APPs are trained to identify and manage a wide spectrum of complications.
Neurologic: Calcineurin inhibitors (CNIs), such as tacrolimus and cyclosporine, can cause neurotoxicity—manifesting as tremors, seizures, or posterior reversible encephalopathy syndrome. Stroke risk is elevated due to embolic events and anticoagulation, while long-term cognitive changes, anxiety, and posttraumatic stress disorder are common.
Ophthalmic: Long-term corticosteroid use necessitates screening for cataracts and glaucoma. Cytomegalovirus (CMV) retinitis, though rare, should be considered in patients presenting with visual complaints.
Pulmonary: Primary graft dysfunction may present acutely postoperatively. Acute cellular rejection is typically confirmed via transbronchial biopsy in patients with unexplained respiratory symptoms or declining PFTs. Long-term surveillance focuses on chronic lung allograft dysfunction, including bronchiolitis obliterans syndrome and restrictive allograft syndrome. Airway complications often require bronchoscopic intervention.
Phrenic and diaphragmatic: Phrenic nerve injury and diaphragmatic paralysis can present as dyspnea, weak cough, or paradoxical breathing. These complications are more common in bilateral lung transplant recipients and may necessitate noninvasive ventilation.
Cardiovascular: Hypertension, dyslipidemia, and arrhythmias are common and multifactorial. APPs assist in managing antihypertensive therapy, rhythm monitoring, and surveillance for right ventricular dysfunction in patients with preexisting pulmonary hypertension.
Endocrine and metabolic: Posttransplant diabetes is often induced by CNIs and corticosteroids. Weight gain and dyslipidemia contribute to metabolic syndrome. APPs play a key role in monitoring blood glucose, managing insulin regimens, and coordinating with endocrinology.
Gastrointestinal: Gastrointestinal (GI) symptoms may arise from medications or opportunistic infections such as CMV. APPs monitor liver enzymes for hepatotoxicity, manage reflux and peptic ulcer prophylaxis, and evaluate persistent GI symptoms promptly.
Renal: Nephrotoxicity from CNIs necessitates regular monitoring of renal function and electrolytes. Chronic kidney disease significantly impacts survival and may require eventual renal replacement therapy.
Musculoskeletal: Chronic steroid use contributes to osteoporosis, avascular necrosis, and muscle wasting. APPs coordinate DEXA screening, initiate bone-protective therapies, and direct patients to physical therapy to prevent frailty.
Dermatologic: Patients who are immunosuppressed are at high risk for skin cancers, particularly squamous cell carcinoma. Routine dermatologic screening and sun protection education are essential.
Distinguishing infection from rejection: A foundational principle in transplant care is discerning infection from rejection, as their treatments are diametrically opposed. APPs are trained to recognize subtle signs of both, especially in patients with nonspecific symptoms or atypical presentations due to immunosuppression.
Close monitoring of posttransplant CNI levels, renal function, and timing is essential. APPs often serve as the first point of contact in managing these nuanced decisions and should be consulted by general pulmonologists managing posttransplant patients.
Optimizing care
APPs are integral to the success of lung transplant programs. Their clinical expertise, consistency, and adaptability allow them to manage the complexity of transplant patients across care settings. By serving as educators, coordinators, and care providers, APPs not only improve outcomes but also extend specialized transplant care to community providers and nontransplant pulmonologists. In the evolving landscape of transplant medicine, APPs are not only valuable—they are indispensable.
This article was originally published in the Fall 2025 issue of CHEST Physician.
References
1. Adegunsoye A, Strek ME, Garrity E, Guzy R, Bag R. Comprehensive care of the lung transplant patient. Chest. 2017;152(1):150-164. doi:10.1016/j.chest.2016.10.001
2. Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021;40(11):1349-1379. doi:10.1016/j.healun.2021.07.005
