Lung transplantation became a reality in 1963 when Dr James Hardy performed the first successful single lung transplant1 in a patient with chronic pulmonary disease and bronchogenic carcinoma. His patient survived 18 days, eventually succumbing to renal failure. His opportunity for success was hampered by a lack of adequate immunosuppressive agents, limited perioperative monitoring, and a lack of adequate support systems such as haemodialysis. Over the next two decades numerous lung transplants were performed. Although all ended as failures, valuable information and experience accumulated in the areas of immune system alteration, diagnosis and treatment of rejection, and opportunistic infections.2 The role of prophylactic antibiotic regimens was better defined. Since the mid 1980s many of these issues have been resolved, and many centres currently perform lung transplantation with progressively better survival rates. The availability of cyclosporin as an immunosuppressive agent allowed reduced doses of corticosteroids to be used and has had a dramatic impact on the successful outcome of lung transplantation. The latest report from the United Network for Organ Sharing (UNOS)3 in the USA recognises 95 centres registered to perform heart-lung transplants and 91 to perform lung transplantation. As more centres have the technological expertise to perform transplantation, and as this technology expands to treat a wider range of chronic lung diseases, there has been an inevitable increase in the number of patients listed for transplantation and, consequently, significant prolongation of waiting times. This is a problem which is now affecting all countries with active transplant programmes; in this paper these problems are discussed in relation to data for transplantation in the USA.

Transplant physicians have constantly to analyse this fluctuation in waiting times. Patients must “get in” in the UNOS list at a time when they are significantly and irreversibly impaired by their chronic pulmonary disease, …