Outcomes of lung transplantation from asphyxiation donors: reassessing hypoxic injury and implications for donation after circulatory death.

Abstract

Objectives: With persistent donor shortages limiting lung transplantation (LT), optimizing the use of extended-criteria donors is essential. Asphyxiation (AXP) and donation after circulatory death (DCD) donors both experience hypoxic-ischemic injury, raising concern for graft performance. We evaluated the long-term outcomes of AXP donor LT and the effect of ex-vivo lung perfusion (EVLP) on survival.

Methods: Adult recipients (≥18 years) of primary LT (2014-2024) in the United Network for Organ Sharing registry were stratified by donor cause of death: AXP vs non-AXP. Survival was estimated by Kaplan-Meier analysis, and multivariable Cox regression identified factors associated with mortality. Subgroup analyses examined EVLP and DCD versus donation after brain death (DBD) cohorts.

Results: Among 26,334 LT recipients, 1,406 (5.3%) received AXP donor lungs. AXP donors were more frequently DCD (9.5% vs. 6%, p<0.001). Ten-year recipient (25.2% vs 27.4%; p=0.67) and graft (24.1% vs 26.8%; p=0.72) survival were comparable, and AXP status was not independently associated with mortality after adjusting for allocation era (HR 1.01, 95% CI 0.91-1.11, p=0.908). However, EVLP use in AXP lungs correlated with decreased 3-year survival (55.3% vs. 74.1%; p=0.035). Sensitivity analyses demonstrated significant differences among the four donor subgroups (DCD-AXP, DCD non-AXP, DBD-AXP, DBD non-AXP) on overall comparison (p=0.008), with DCD-AXP recipients exhibiting numerically highest 5-year survival rates.

Conclusions: AXP donor lungs provide comparable long-term outcomes, and DCD-AXP grafts do not appear to confer inferior survival. The interaction between AXP and EVLP use warrants further study to refine donor reconditioning strategies.