Lung transplantation following donation after circulatory death: Five-year US experience

Donation after circulatory death lung allografts offer promise to expand the donor pool. As novel procurement and preservation techniques like normothermic regional perfusion and ex vivo machine perfusion gain adoption, their impact on allograft utilization and outcomes remains unclear. We evaluated national trends in donation after circulatory death lung utilization and assessed 3-year survival stratified by procurement and preservation strategy.

We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database for all adult (≥18 years) lung transplant recipients from December 1, 2019, to March 31, 2025. Allografts were categorized as donation after brain death or donation after circulatory death and stratified by procurement technique and perfusion strategy: standard recovery with static cold storage, direct procurement, or normothermic regional perfusion, with or without ex vivo machine perfusion. The primary outcome was 3-year survival, using cox proportional hazards modeling.

Donation after circulatory death allografts had lower odds of procurement and transplant than donation after brain death / standard recovery with static cold storage (adjusted odds ratios: normothermic regional perfusion / static cold storage 0.25, direct procurement / static cold storage 0.18, P < .001), although normothermic regional perfusion / static cold storage allografts exceeded direct procurement / static cold storage (adjusted odds ratio 1.40, P = .001); odds were similar between normothermic regional perfusion / ex vivo machine perfusion and direct procurement / ex vivo machine perfusion (adjusted odds ratio 1.05, P = .90). Three-year survival was comparable between donation after circulatory death / normothermic regional perfusion-static cold storage (hazard ratio 1.02, confidence interval 0.46-2.28, P = .96), donation after circulatory death / direct procurement-static cold storage (hazard ratio 1.19, confidence interval 0.97-1.45, P = .09), donation after brain death / standard recovery-ex vivo machine perfusion (hazard ratio 1.10, confidence interval 0.86-1.41, P = .44) and donation after circulatory death / normothermic regional perfusion-ex vivo machine perfusion (hazard ratio 1.81, confidence interval 0.57-5.76, P = .32). Compared with donation after brain death / standard recovery with static cold storage, donation after circulatory death / direct procurement-ex vivo machine perfusion demonstrated similar 1-year survival (hazard ratio 1.30, confidence interval 0.81-2.11, P = .28) but increased 3-year mortality (hazard ratio 1.47, confidence interval 1.03-2.09, P = .04).

Most donation after circulatory death lung allografts demonstrate comparable midterm survival to traditional allografts across procurement and preservation methods. Ongoing evaluation of outcomes and utilization across these methods is essential to guide best practices and inform future adoption.