Lung Transplantation is now an established therapy for end-stage parenchymal lung and vascular diseases. Around 1000 lung transplants have been done at the Alfred Hospital Melbourne since 1990, representing ~3% of all those done worldwide. Much has been learnt about the clinical medical management of these patients and in 2013 a 95% 1year and 70% 5 year survival is expected. The basic science behind the clinical face has evolved too. Histological assessment of the endstage disease at explant has taught us that some diseases (eg. interstitial lung diseases) rarely provide late surprises, whereas others (eg. emphysema, bronchiectasis) can reveal novel important findings (eg. cancer, fungal infection, pulmonary emboli). Histological assessment of the new allograft is the cornerstone of diagnosing cellular acute rejection. Unfortunately, the pathological diagnoses of antibody-mediated rejection (AMR) even with CD31 and C4d staining, is way behind the diagnositic confidence currently seen in renal and cardiac allograft AMR. In combination with microCT scans and elastin stains, recent insights are starting to unravel chronic lung allograft rejection. The development of clinical donation-after-cardiocirculatory death (DCD) lung donation has raised awareness that the lung is more robust to ischaemia than previously thought. Ex-vivo lung perfusion and histological assessment of DCD donors notes cell death and apoptosis, but functionally the lung can recover. Putting all this together, we expect to see increasing lung transplant donors from novel sources and hopefully better long term outcomes.