Imagine facing a life-threatening lung disease and being told a transplant is your best hope. Then, you learn you have a stubborn, hard-to-treat infection called NTM. Suddenly, the path forward feels unclear. Should you still be eligible for a transplant? Will the infection come back after the surgery?
This is a real and difficult situation for many people with cystic fibrosis (CF).
A Tough Decision for Patients and Doctors
Cystic fibrosis is a genetic condition that causes thick, sticky mucus to build up in the lungs. This leads to frequent infections and makes it harder to breathe over time. For some, a lung transplant becomes the only option to extend life and improve quality of life.
However, a lung infection with nontuberculous mycobacteria (NTM) complicates things. NTM are bacteria found in soil and water. For most healthy people, they aren’t a problem. But for someone with CF, they can cause serious, ongoing lung damage.
Doctors have been unsure whether having NTM should automatically disqualify someone from getting a transplant. The fear is that the infection could spread to the new lungs or the rest of the body after surgery.
Old Beliefs vs. New Evidence
In the past, many transplant centers were hesitant to operate on patients with active NTM infections. The risk seemed too high. But guidelines have started to shift, suggesting that NTM alone shouldn’t be an automatic "no."
This new Cochrane review pulls together all the available evidence to see what actually happens to CF patients with NTM who get a lung transplant.
How the Review Worked
Researchers searched for all relevant studies on this topic. They found four small, single-center studies from the past. All studies were "retrospective," meaning they looked back at medical records rather than following patients forward in time. In total, the studies included 388 adults with CF.
The researchers compared two main groups: 1. CF patients with NTM who received a lung transplant. 2. CF patients without NTM who received a lung transplant.
They looked at key outcomes like survival, whether the NTM infection spread after transplant, and the development of chronic lung rejection (called CLAD).
The results were mixed and, at times, contradictory. The overall certainty of the evidence was rated as "very low," meaning we cannot be confident in the findings.
Survival Rates
One large study found that CF patients with NTM before their transplant actually lived longer than those without NTM. Another small study had different results, showing some deaths soon after transplant in the NTM group. Because the studies are small and conflicting, we can’t draw a firm conclusion about survival.
NTM Infection After Transplant
The risk of NTM spreading after transplant appears to be higher in patients who had it before surgery. In the largest study, about 40% of patients with NTM before transplant developed active NTM disease afterward. In contrast, none of the patients who started without NTM developed the disease after transplant.
Chronic Lung Rejection (CLAD)
Only two studies looked at this. One found no difference in rejection rates between the two groups. The other reported that some patients with NTM developed chronic rejection. Again, the evidence is too limited to be sure.
This is where things get interesting. The data is messy, but it doesn't automatically say "no" to transplant for these patients.
The authors of the review emphasize that there are no randomized controlled trials—gold-standard studies—to guide these decisions. All the evidence comes from small, observational studies. This means doctors and patients are making decisions based on very uncertain information.
In an era where new CF treatments (called modulators) are improving lung function, the need for transplant may change. But for those who still need it, the question of NTM remains urgent.
If you or a loved one has CF and NTM, and a lung transplant is being considered, this review shows that it’s not an automatic disqualifier. However, the decision is complex and must be made with a specialist transplant team. They will weigh the uncertain risks and benefits based on your specific situation.
This doesn’t mean this treatment is available yet or without risk.
This review has major limitations. The studies were small, non-randomized, and came from single centers. The results are often contradictory. The certainty of the evidence is very low, so the true effect of NTM on transplant outcomes remains unknown.
The authors conclude that there is an urgent need for more research. Larger, well-designed studies are needed to give patients and doctors clear, reliable data. Until then, decisions about lung transplantation in CF patients with NTM will continue to be made on a case-by-case basis, guided by the best available—but very uncertain—evidence.