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The Registry of the International Society for Heart and Lung Transplantation (ISHLT) has reported survival rates of 64% and18% at 1 and 14 years, respectively, for heart–lung transplantation and of 70%, 45% and 20% at 1, 5 and 10 years, respectively, for lung transplantation [1]. Despite the increasing range and sophistication of immunosuppressive and antimicrobial drugs, the main causes of morbidity and mortality occurring after the immediate postoperative period remain acute rejection, infection and, in late survivors, obliterative bronchiolitis. In order to improve the results of lung transplantation, early diagnosis and treatment of post operative complications are essential. The his to pathologist has a role to play in this process in terms of biopsy diagnosis of, and research into, the pulmonary and systemic complications (Table 23.1) and in contributing to clinical audit through postmortem examination [2]. In addition, review of lung biopsies taken prior to transplantation may confirm the referral diagnosis, which, in turn, is audited by histological examination of the explanted lung. In a small number of cases this may reveal a different, or an additional diagnosis, sometimes in the context of systemic disease, with implications for post-transplantation management [3] (see Chapter 10).