Lung transplantation is an increasingly common therapeutic option in end-stage pulmonary diseases. One of the main causes of medium and long-term graft failure is chronic rejection, clinically represented by bronchiolitis obliterans syndrome. The early diagnosis of chronic rejection allows optimization of immunosuppressive therapy in order to delay its progression.In this paper, we review and illustrate the characteristics of chronic lung rejection in high-resolution computed tomography to promote its early diagnosis in follow-up examinations.At an early stage, during the first year after transplantation, subtle features such as reduction of peripheral bronchovascular markers, thickening of the septal lines, and decreased lung volumes may suggest the diagnosis even before clinical changes appear. Mid-term features are represented by bronchiectasis and bronchial wall thickening, and present low sensitivity, but high specificity in the diagnosis of chronic rejection. Its appearance occurs simultaneously with the clinical diagnosis of bronchiolitis obliterans syndrome. Lung attenuation abnormalities appear in late stages of the disease. Air trapping is related with small airway obstruction and mosaic attenuation pattern with ventilation-perfusion mismatch. Fibrotic changes of the lung parenchyma characterize advanced stages of chronic graft rejection, leading to important functional repercussion.High-resolution computed tomography has helped to overcome the limitations of clinical criteria in the diagnosis of obliterans bronchiolitis syndrome and promoted an earlier diagnosis of chronic rejection after lung transplantation
