The International Society of Heart and Lung Transplantation (ISHLT) recently released guidance regarding frailty in lung transplantation. The guidance statement, Assessing and Addressing Frailty in Candidates for Lung Transplantation: An ISHLT Consensus Statement, features 20 consensus recommendations covering topics including best practices in choosing a frailty assessment measure, exercise interventions following frailty identification, and more. 

Today, we’re showcasing the recommendations found within the ISHLT 2026 frailty in lung transplant guidance. For the complete look at the following recommendations, along with their provided rationale, view the full-text version of Assessing and Addressing Frailty in Candidates for Lung Transplantation.

Recommendation from ISHLT 2026 Frailty in Lung Cancer Guidance

Defining Frailty: Post-Transplant Outcomes

  • Pre-transplant physical frailty attributable to advanced lung disease may reverse after lung transplantation. 
  • Programs should consider potential reversibility of frailty and program capacity to support recovery when selecting candidates with frailty for lung transplantation.

Best Practices in Choosing a Measure to Assess Frailty in Lung Transplant Candidates

  • We recommend that objective frailty measures be incorporated into the multidisciplinary candidate evaluation and selection process.
  • We recommend that programs select a measure that has been rigorously studied in a lung transplant population and supports the reliable capture and use of data to inform clinical decision-making.

Program Goals

  • We recommend that programs identify programmatic goals prior to selecting and implementing a frailty assessment instrument. 
  • We recommend that transplant programs incorporate results from standardized frailty assessments into discussions with individual patients and their caregivers to help set care-related expectations.
  • We recommend that programs track relevant findings and outcomes to evaluate whether assessments are achieving the stated programmatic goals.

Feasibility

  • We recommend that all transplant programs perform frailty screening on all transplant candidates.
  • Selective frailty screening may be considered if the frailty assessments are used exclusively for institutional resource planning.

Best Practices for Assessing Frailty in the Inpatient Setting

  • We recommend that hospitalized lung transplant candidates have a frailty assessment upon their initial admission or initial lung transplant consultation to guide intervention strategies, including discussions of ECMO BTT.
  • We recommend development of a frailty measure specific for use in critically ill lung transplant candidates.

Exercise Interventions When Frailty is Identified

  • All lung transplant candidates, including those on mechanical support, should be considered for exercise interventions, in parallel with the evaluation process.
  • The recommended frequency for exercise interventions is at least 3 sessions per week, but daily exercise is recommended for all lung transplant candidates.
  • The recommended exercise interventions for prehabilitation should include lower limb resistance/strength training and endurance (mobilization and or stationary cycling) as tolerated.
  • Home-based and virtual exercise interventions are acceptable alternatives to center-based programs, depending on the candidate’s situation and resources of the transplant center.

Nutritional Interventions When Frailty is Identified

  • We recommend that individualized nutritional supplementation be used alongside exercise interventions to reverse sarcopenia and prevent or improve frailty in lung transplant candidates.
  • We recommend that all candidates be screened for malnutrition and have nutritional status monitored throughout the continuum of care.

Integrating Response to Exercise Interventions into Clinical Decision-Making

  • Frailty assessments should be repeated at intervals when their results are likely to inform or influence clinical team decision-making.

Considerations for Post-Transplant Frailty

  • Assessment of frailty after lung transplantation should be performed using similar measures and managed using similar interventions to the pretransplant approach.
  • Changes in clinical status after lung transplantation, such as the development of CLAD, may warrant repeat frailty assessments and interventions to improve symptoms and quality of life.

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