Prioritization and Severe Primary Graft Dysfunction after Lung Transplantation

Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation (LTx). Critically ill candidates may receive priority on the transplant waiting list; however, the relationship between prioritization and the development of severe PGD remains unclear.

We performed a retrospective analysis of a prospectively maintained cohort including all consecutive LTx performed at a tertiary center between January 2016 and June 2025. Recipients were categorized according to prioritization status. Severe PGD was defined as grade 3 PGD according to the International Society for Heart and Lung Transplantation criteria. Clinical characteristics and outcomes were compared between prioritized and non-prioritized recipients. Logistic regression was used to identify predictors of severe PGD, and survival was evaluated using Kaplan-Meier analysis.

Among 310 LTx recipients, 74 (23.8%) were prioritized. They were younger, had a higher prevalence of pulmonary hypertension, and were more frequently hospitalized before transplantation, particularly in the intensive care unit. Severe PGD occurred more often among prioritized recipients (24% vs 7%). However, prioritization was not independently associated with PGD after adjustment. Pre-transplant extracorporeal membrane oxygenation support emerged as the strongest independent predictor of severe PGD. Thirty-day mortality was similar between groups, whereas prioritized recipients had higher 90-day and 1-year mortality.

Prioritized LTx recipients have greater pre-transplant clinical severity, higher crude rates of severe PGD, and worse short-term survival. However, prioritization itself was not independently associated with PGD, suggesting that underlying disease severity and need for advanced support are the main drivers of post-transplant outcomes.