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Originally published August 25, 2025
Last updated August 25, 2025
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For most patients in dire need of an organ transplant, a transplant is their only hope of survival. Unfortunately, too often patients — especially those with advanced lung diseases like chronic obstructive pulmonary disease (COPD), pulmonary hypertension and pulmonary fibrosis — are referred to a transplant center after the window of opportunity for a transplant has closed.
Sivagini Ganesh, MD, is raising awareness about this ongoing problem. Ganesh is a pulmonary critical care specialist and medical director of the USC Lung Transplantation Program, part of the USC Transplant Institute and Keck Medicine of USC. The USC Transplant Institute also provides advanced heart, liver and lung transplant care and complex hepatobiliary care to patients living in Southern Nevada at its state-of-the-art facility Keck Medicine of USC – Las Vegas.
There are several reasons why some community physicians don’t refer severe lung disease cases to a transplant center early enough, Ganesh says.
Many will first try to exhaust all other treatment options — primarily medication. For instance, they may try inhaled medications, or even new medications for pulmonary fibrosis, and wait to see if these help. Unfortunately, they may wait too long before moving to the inevitable: a lung transplant.
“Their approach is to treat the patient as long as they can,” Ganesh says. “When everything else fails, only then will they refer the patient for a transplant.”
Some physicians additionally aren’t familiar enough with the transplant process to recognize the opportune point of referral. “Many physicians in the community are not exposed to the world of transplant during their training, and that’s another reason patients don’t get referred on time,” she says.
“What they should understand, however,” she continues, “is that when they refer a patient too late, the patient may be declined for a transplant because by that time the patients are too sick to be transplanted.”
When is the ideal time to refer a patient? Ganesh describes the “good window.”
“Patients should be able to walk around and be physically functional,” she says. “They should be able to carry out tasks of daily living and also be able to manage their medication.”
By contrast, “When patients are bed-bound and needing high amount of oxygen, physically deconditioned and unable to get out of bed and in complete need of assistance, a transplant is not going to be successful.”
She adds that the International Society for Heart and Lung Transplantation (ISHLT) has established guidelines for how to manage patients with advanced heart and/or lung disease — including when to refer patients for a transplant.
Many steps, and a lot of time, precede getting a patient listed on a lung transplant wait list.
“The referral process starts when a pulmonologist, internal medicine physician or even a cardiologist encounters a patient with end-stage lung disease like COPD, lung fibrosis, bronchiectasis or pulmonary hypertension,” Ganesh says. “These patients need significant amount of support, and when their physician feels their condition is medically not manageable, they’ll refer them for a transplant.”
The transplant center then works to obtain financial clearance from the insurance company to start evaluating the patient. Evaluation is extensive and includes all organ systems, which usually takes months for completion.
Ganesh explains that the time required for testing can differ depending on whether a patient is an inpatient or an outpatient. For inpatients, testing takes a full week to complete.
Most insurance companies, however, require patients to be treated as outpatients due to cost. For outpatients, testing can take anywhere from three to six months to complete due to the number of tests required and the ability of a patient with poor lung function to come to the testing place. “If you order multiple tests for an outpatient, the patient must go back and forth to the hospital for testing,” Ganesh says.
“If possible,” she says, “we prefer to do an inpatient workup because these patients who need a transplant are already sick and on five or six liters of oxygen. As outpatients, commuting to and from the hospital can be very challenging for them. If they are an inpatient, we do all the testing needed within seven days and then move the patient to the next level, which is listing.”
Doctors and patients should be aware of the potentially long testing time. “Patients and their doctors need to anticipate enough time in advance for the testing to be done, especially for outpatients,” Ganesh advises.
If a patient is very ill, on rare occasion a transplant center may be able to convince an insurance company that the patient needs to be admitted as an inpatient, but this doesn’t always work. Other times, if a patient is sent to an outside hospital because they are too sick, there’s a chance that an insurance company may eventually agree to have the patient transferred to a transplant center as an inpatient. It’s always a gamble, however.
“Unfortunately,” Ganesh says, “some patients will pass away before they get to listing because they are very sick.”
For patients who do complete testing, their case will be discussed in a multidisciplinary meeting to determine whether the patient would be a good transplant candidate. “We all meet together: the pulmonologist, the surgical teams, physical therapists, occupational therapists, dietitian coordinators, financial representatives and other subspecialists like cardiologists, psychiatrists, infectious disease specialists and pharmacists,” Ganesh explains. “We discuss the patient and decide whether they are going to be a good candidate or not. If they are a good candidate, then we list them.”
The process, she emphasizes, is long. “This is why when referring physicians ask if their patient is going to be listed soon, the answer is no. That is why we want patients referred early on so that they can make it through the testing to determine whether they are going to be good candidates.”
It’s very rare, but sometimes a physician can try to refer a patient to a transplant center prematurely, Ganesh says. If this happens, the transplant center won’t list the patient — yet.
“If you’re going to transplant someone, we make sure it’s the appropriate time for that specific patient,” she says. “Transplant is a major surgery that comes with complications. We don’t just transplant everyone who is referred; we transplant those who need it most.”
If a patient is referred too early, “We’ll call the referring physician back and tell them the patient is too early for a transplant,” she says. “We notify them to keep us informed about the patient’s clinical status and pulmonary function test numbers, and if the numbers start to drop further, to call us back.”
Ganesh’s goal is to raise awareness among referring physicians about the optimal time to refer a patient. It’s dangerous to believe that patients must be treated maximally first and only referred for transplant when all else fails, she says.
“That thinking process must change,” she says. “Doctors should not be thinking of a transplant as a very last option. Their thinking process should change to include lung transplant as another treatment modality they are providing to the patient. Lung transplants should be part and parcel of treatment planning. If a patient falls under the guidelines of needing to be referred, they can be referred while still receiving treatment such as the medications they need.”
Ganesh points to one last reason why some physicians may wait until the last minute to refer: “Once they refer, they feel like they are losing their patient to another center and that the patient won’t come back to them.”
When community doctors refer patients, Ganesh says she makes a point of working collaboratively with them early on. “I try to reassure them that after we transplant the patient, the patient will come back to them for future follow-up. We will take care of the transplant piece; they can take care of the rest of the patient.”
There is still a lot of progress to be made in spreading these messages. “In my experience, I don’t get the phone call that says, ‘Hey, I saw a pulmonary fibrosis patient today for the first time. These are the numbers. Can I plug this patient into a transplant center?’” Ganesh says. “I don’t get that call. I get the call that says, ‘Oh, the patient is intubated; there’s nowhere to go. Can you take this patient?’ So, I will emphasize that shift must happen. Otherwise, we are going to lose a lot of patients to these diseases without getting them a transplant.”
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