Telomere biology disorders in lung transplantation: Clinical challenges and management strategies.

Telomeres, repetitive DNA sequences at the ends of chromosomes, play a crucial role in maintaining genomic stability. In recent years, their significance in lung transplantation has gained growing attention. Shortened telomeres-whether due to inherited telomeropathies or acquired attrition-have emerged as a risk factor for various pulmonary diseases, particularly pulmonary fibrosis, which is a leading indication for lung transplantation. This review provides a comprehensive overview of current knowledge on the impact of short telomeres in lung transplant recipients, encompassing pre-transplant assessment and post-transplant outcomes. Patients with telomere-biology disorder present unique clinical challenges. Before transplantation, they may exhibit extra-pulmonary manifestations such as bone marrow dysfunction, hepatic abnormalities, precipitation to develop cancer, all of which necessitate a tailored evaluation and multidisciplinary management. After transplantation, these patients appear to be at increased risk of complications, including drug-related hematologic toxicity, bone marrow failure, and heightened susceptibility to infections. The review emphasizes the importance of identifying patients with telomere biology disorders early in the transplant process and supports the incorporation of telomere length testing in selected populations. Furthermore, it highlights the need for adjusted immunosuppressive strategies and closer surveillance in this vulnerable population. Ultimately, the authors advocate for prospective, multicenter studies aimed at refining the prognostic value of telomere length and guiding evidence-based, individualized transplant strategies for patients with telomere biology disorders related interstitial lung diseases.