Background: Despite advancements in pharmacological therapy, lung transplantation (LuTX) remains the only life-prolonging treatment in end-stage idiopathic pulmonary fibrosis (IPF). However, real-world referral patterns in Central and Eastern European (CEE) countries remain poorly characterized. We aimed to comprehensively review factors influencing referral and identify systemic barriers to LuTX access. Methods: Baseline characteristics of IPF patients potentially eligible for LuTX, enrolled in the European MultiPartner IPF Registry between 2012 and 2022 (n = 1256), were retrospectively analyzed. LuTX (n = 94) and potentially eligible but not transplanted (n = 1162) subgroups were compared. National experts also completed a questionnaire assessing transplant referral and listing practices across different healthcare systems. Results: Only 7.5% of potentially eligible subjects were transplanted, revealing substantial geographic disparities, with Israel having the highest rates (43.1%), followed by Austria (9.5%), Hungary (7.8%), and the Czech Republic (4.6%). LuTX patients were younger (60.2 ± 7.4 vs. 62.6 ± 6.2 years, p < 0.001), had worse lung function (FVC 60 ± 15 vs. 74 ± 21% predicted; p < 0.001, TLCO 41 ± 15 vs. 49 ± 19% predicted; p < 0.001), and were more likely to receive antifibrotic and oxygen therapies. The most frequent reasons for exclusion from referral/listing were age > 70 years and concomitant heart/renal failure. Conclusions: This first comprehensive CEE analysis demonstrates low IPF transplant rates with high inter-country variability. Patients presenting early with functionally advanced disease are more likely transplanted, while advanced age remains the primary exclusion factor, highlighting critical access gaps potentially contributing to regional outcome differences.

1st Department of Pulmonary Diseases Institute of Tuberculosis and Lung Diseases 01 138 Warsaw Poland

Clinic for Pulmonology University Clinical Center of Serbia 11000 Belgrade Serbia

Clinic of Pneumology and Phthisiology University Hospital Bratislava 826 06 Bratislava Slovakia

Department of Pulmonary Medicine Ege University Medical School Izmir 35100 Turkey

Department of Pulmonology Semmelweis University 1083 Budapest Hungary

Department of Respiratory Medicine Paracelsus Medical University 5020 Salzburg Austria

Department of Respiratory Medicine Thomayer University Hospital 14059 Prague Czech Republic

Faculty of Medicine University of Belgrade 11000 Belgrade Serbia

Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University 62500 Brno Czech Republic

Institute of Pulmonary Medicine Rabin Medical Center Petah Tikva 49100 Israel

PHI University Clinic of Pulmonology and Allergy Faculty of Medicine University Ss Cyril and Methodius 1000 Skopje North Macedonia

Pulmonary Department Acibadem City Clinic Tokuda Hospital Sofia 1407 Sofia Bulgaria

Pulmonary Department University Hospital Dubrava 10 000 Zagreb Croatia

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