Beyond boundaries: Redefining the donor frontier in pediatric lung transplantation

Lung transplantation remains the optimal treatment for children with end-stage lung disease, yet donor organ shortage represents the greatest obstacle to transplantation. In 2023, only 31 pediatric lung transplants were performed in the United States, with 9% of recovered lungs ultimately not transplanted. Pediatric waitlist mortality has increased, particularly for patients under one year of age, necessitating innovative strategies to expand the donor pool.

This review examines emerging strategies to combat organ shortage in pediatric lung transplantation, including extended criteria donors, deceased cardiac death (DCD) organ donation, ex-vivo lung perfusion (EVLP), graft size reduction techniques, living donor lobar transplantation, and utilization of hepatitis C and HIV-positive donor organs. We analyzed current literature and clinical outcomes data to assess the feasibility and safety of these approaches in pediatric populations.

Extended criteria donors now account for 80% of lung transplants without compromising short- and mid-term pediatric outcomes. DCD lung transplantation demonstrates comparable survival rates to brain-dead donors, with only 14 DCD organs used in pediatric programs between 2004-2022. EVLP shows promise in preserving organ viability and reducing primary graft dysfunction. Hepatitis C-positive donors demonstrate excellent outcomes with direct-acting antiviral therapy in adult patients, but scant literature is available in the pediatric population. Reduced-size grafts and living donor procedures offer solutions for size-mismatched recipients.

Multiple innovative strategies show potential for expanding the pediatric lung donor pool. While adult data demonstrates safety and efficacy, pediatric-specific research remains limited. Continued scientific inquiry, active donor management protocols, and interdisciplinary cooperation are essential to safely implement these approaches and improve access to life-saving transplantation for children.