Lung transplantation from donation after circulatory death, evolution and current status in the United States

Purpose: To describe the evolution and outcomes following lung transplantation with lungs from donors after circulatory determination of death (DCD) and to report practices and outcomes with ex vivo lung perfusion (EVLP) in this donor population.

Methods: This is a retrospective study, of a prospectively collected national registry. The United Network for Organ Sharing (UNOS) database was queried to identify adult patients who underwent lung transplantation from January 1, 2012, through December 31, 2021. When examining EVLP data, the dataset was limited to 2018 and after due to inconsistent and low sample size prior to 2018. Kaplan-Meier analyses were used to compare survival in the 4 cohorts (the donation after brain death (DBD) with or without EVLP, DCD with or without EVLP). The primary outcome of interest was overall survival. Secondary outcomes included postoperative events, such as primary graft dysfunction, and days on the ventilator.

Results: A total of 30,999 patients met the inclusion criteria for the study. Within the sample, 29,917 (96.5%) transplants received DBD lungs and 1,082 (3.5%) received DCD lungs. There was a significant increase in the availability of DCD donors during the study period, increasing from 7.5% of available donors in 2005 to over 30.2% of available donors in 2021 (p < 0.001). Additionally, there was a significant increase in the acceptance of DCD donors for lung transplants, increasing from less than 1% (0.57%) of lung transplants in 2005 to over 8.1% in 2021 (p < 0.001). Of the 21,356 patients who underwent lung transplantation, 20,380 (95.4%) transplants received DBD lungs and 976 (4.6%) received DCD lungs. Recipients of DCD lungs were more likely to experience acute rejection, severe primary graft dysfunction, require post-transplant ventilation and for longer durations, and require post-transplant dialysis relative to DBD lung recipients. Recipients of DCD lungs with EVLP had longer total ischemic time (12.7 hours vs. 6.3 hours) relative to those without EVLP. DCD lungs with EVLP recipients had significantly shorter survival time relative to DBD without EVLP lungs recipients (median: 1456 days vs. 1545 days; p = 0.002).

Conclusion: Lung transplantation from DCD is on the rise in the United States and survival rates are comparable to those of DBD. However, the survival rate of lung transplantation from DCD with EVLP group is inferior to those from DCD without EVLP group or those from DBD group. The poor survival observed in recipients of DCD lungs that were screened with EVLP requires further investigation. Unfortunately, the UNOS registry does not capture differences among EVLP methods limiting the interpretation of our observations.

Identify the source of the funding for this research project: None