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Ex-vivo lung perfusion(EVLP) may allow for evaluation and rehabilitation of marginal donor lungs, including those from donation after circulatory death(DCD) donors, with outcomes understudied. We evaluated the short-term and mid-term outcomes of DCD lungs managed with or without EVLP. We conducted retrospective review of the United Network for Organ Sharing(UNOS) registry of all primary adult DCD lung transplants performed from February 18, 2018 onwards, dichotomizing them as those managed with or without EVLP. Baseline characteristics and short-term outcomes were compared. Two-year survival was examined with Kaplan Meier curves and multivariable Cox proportional hazards regression. Of 757 DCD lung transplants, 189(25%) were managed with EVLP with no significant differences in donor characteristics. Recipients of EVLP-managed lungs had longer wait-list duration(40 vs 32 days, p=0.01), longer organ preservation times(12.6±3.8 vs 6.6±2.2 hours, p<0.01), and longer distance traveled[268 (98-490 vs 132(49-305) nautical miles, p<0.01]. Recipients of EVLP-managed DCD lungs were more likely to remain intubated (51% vs 43%, p=0.04), be on ECMO (22% vs 14%, p<0.01), and have grade 3 primary graft dysfunction (31% vs 23%, p=0.04) at 72 hours. One(86% vs 77%) and two-year(74% vs 65%, log-rank p=0.02) survival were significantly worse with EVLP-managed lungs. On multivariable Cox proportional hazards regression, EVLP was significantly associated with worse two-year survival(adjusted HR 1.45, 95% CI 1.01-2.08) when preservation time was not used as an adjuster(EVLP aHR 1.28, 95% CI 0.74-2.21). A quarter of DCD lung transplants are managed with EVLP in the United States, with inferior short-term and mid-term outcomes compared to those not managed with EVLP, possibly related to the obligate increase in preservation times. Further studies are needed to define the role of EVLP in the preservation of DCD lungs prior to transplantation. [ABSTRACT FROM AUTHOR]

The development of modern antiviral therapy for HCV has allowed for the transplantation of HCV NAT+ donor lungs with good short-term outcomes. We sought to evaluate trends and mid-term outcomes of lung transplant recipients of HCV NAT+ donor allografts. All adults undergoing single-organ lung transplantation in the United Network for Organ Sharing database from January 2016 to June 2022 were included in the study. Lung transplant recipients were stratified based on donor HCV NAT status (HCV NAT + vs NAT-). Baseline characteristics and outcomes, including postoperative complications, early (30-day and in-hospital) mortality and both 1- and 3-year survival were compared between groups. A total of 15,414 patients underwent lung transplantation during the study period, with 422 (3%) receiving HCV NAT+ donor lungs. Regions 1 (17%), and 6/8 (both 0%) had the highest and lowest proportions, respectively, of HCV NAT+ donor transplants. Utilization of HCV NAT+ donors steadily increased throughout the study period from 2 (0.1%) in 2016 to a peak of 117 (5%) in 2019. Donors who were HCV NAT+ were older (34 vs 36 years, P<0.001), more often male (55% vs 45%, P<0.01) and categorized as CDC high risk (83% vs 17%, P<0.001). Recipients of HCV NAT+ donor lungs were similar in age (61 vs 62 years, P=0.99) and male gender (57% vs 61%, P=0.15) but had lower lung allocation scores (38 vs 41, P<0.001) compared to others. Rates of postoperative ECMO (7% vs 8%, P=0.34), dialysis (7% vs 8%, P=0.40), reintubation (16% vs 19%, P=0.17) and acute rejection (14% vs 15%, P=0.49) were similar between groups. Additionally, early mortality (both 30-day and in-hospital) as well as 1- and 3-year survival (Figure) were not significantly different between groups. Lung transplant recipients of HCV NAT+ donor allografts experience similar rates of acute rejection, early mortality and 3-year survival compared to all other lung recipients. Increased use of HCV NAT+ donor allografts may help to expand the donor pool and alleviate donor shortages. [ABSTRACT FROM AUTHOR]

Ex-vivo lung perfusion (EVLP) can be used to assess and rehabilitate donor lungs to expand the donor pool. However, the frequency of EVLP utilization and its outcomes are not well-studied. The goal of this study was to describe the characteristics and outcomes of lungs transplants performed with EVLP in the US. We conducted retrospective review of the UNOS registry of all primary adult lung transplant recipients from Feb 28, 2018 to June 30, 2021, excluding recipients with prior transplants, multiorgan transplants, and those waitlisted for other organs. Lung transplants were dichotomized as those that were performed with EVLP versus no EVLP. Baseline characteristics and short-term outcomes were compared. One-year survival was assessed by the Kaplan Meier method and multivariable Cox proportional hazards regression. Of 8,204 lung transplants performed during our study period, 426(5.2%) were performed with EVLP. Perfusion was performed by the OPO in 29(7%), transplant center in 291(68%), and external perfusion center in 106(25%) of cases. EVLP donors were older (39±13 vs 36±14 yrs, p<0.01), more likely DCD (31% vs 5%, p<0.01), and had lower P:F ratio(415±124 vs 442±130, p<0.01). Recipients had lower LAS scores[39(35-53) vs 41 (35-57), p<0.01)]. EVLP lungs traveled further[232(122-489) vs 169 (71-270) nautical miles, p<0.01], had longer ischemic times(11.5±4.1 vs 5.5±1.6 hrs, p<0.01), and were more likely double lung transplants(85% vs 76%, p<0.01). At 72 hours, recipients of EVLP lungs were more likely to remain intubated(47% vs 30%, p<0.01), be on ECMO(16% vs 8%, p<0.01), and experience PGD grade III (24% vs 17%, p<0.01). They also had higher total length of stay[21(13-39) vs 18(13-30) days, p<0.01). EVLP was associated with worse one-year survival on univariable(84% vs 88%, HR 1.41, 95% CI 1.07-1.85, p=0.02) but not multivariable analysis(aHR 1.18, 95% CI 0.88-1.59, p=0.26), particularly after adjusting for DCD donation(aHR 1.46, 95% CI 1.11-1.91) EVLP technology is used in a minority of donor lungs in the United States. A majority of the EVLP procedures are performed by the transplant centers with a higher proportion of DCD donors. The short-term outcomes and one-year survival of recipients of EVLP lungs appear worse than those not managed with EVLP. The role of this technology in the broad filed of lung transplantation remains to be defined. [ABSTRACT FROM AUTHOR]

With the advent of a cure for HCV, HCV NAT+ donor lungs are being increasingly utilized for transplantation, but their outcomes are understudied. Our goal was to examine one-year survival of lung transplant recipients from HCV NAT+ donors. We conducted retrospective review of all primary adult lung transplant recipients in the UNOS registry between January 1, 2015 and June 12, 2020. Donors were identified as being HCV NAT+ or HCV NAT-. One-year survival was examined with the Kaplan Meier method and a multivariable Cox-proportional hazards model. Of 11809 lung transplants performed during the study period, 222 (2%) came from HCV NAT+ donors. HCV NAT+ donors tended to be younger (33±8 vs 35±14 yrs, p=0.01) and were more likely to be white (82% vs 61%, p<0.01), blood group O (61% vs 50%, p<0.01), CDC high risk (84% vs 24%, p<0.01), and have drug intoxication as cause of death (61% vs 12%, p<0.01). Recipients of HCV NAT+ donor lungs were less likely to have diabetes (10% vs 20%, p<0.01), cystic fibrosis (5% vs 9%, p<0.01), IPF (28% vs 36%, p<0.01), have chronic steroid use (32% vs 44%) or be treated with IV antibiotics 2 weeks prior transplant (5% vs 12%, p=0.02). They had lower LAS scores (42±15 vs 48 ± 18, p<0.01), oxygen requirements at rest (4.5 vs 5.5 L, p<0.01), and were more likely to receive double lungs (83% vs 74%, p<0.01). One-year survival was not significantly different among recipients of HCV NAT+ and NAT- donor lungs on univariate (HR 1.00, 95% CI 0.62-1.62, p=0.98) or multivariate analysis (aHR 0.94, 95% CI 0.53-1.67, p=0.84). Incidence of treatment for acute rejection at one year was also not significantly different (23% vs 23%, p=0.86). Despite coming from high-risk donors, HCV NAT+ lungs have similar one-year survival and acute rejection as those coming from HCV NAT- donors. While longer-term studies are necessary, this report supports the use of NAT+ donor lungs among lung transplant candidates. [ABSTRACT FROM AUTHOR]

Donor lungs are insufflated with high oxygen levels during the transport, allowing continued aerobic metabolism. Complex operations are associated with more adverse outcomes, if performed at night. We hypothesized that for donors with cross clamp after 1:30 AM, the recipient operation can be delayed until morning with acceptable short-term outcomes. This study was approved by IRB. From 3/18/18 to 10/16/20, the recipients of all donor lungs whose cross clamp was scheduled after 1:30 AM were prospectively enrolled in this study. Skin incision of the recipient operation was delayed until 6:30 AM. A contemporary cohort of lung transplant recipients who were matched in age, diagnosis group, Lung Allocation Score and the procedure type served as control and in-hospital outcomes were examined. During this interval, 27 lung transplant recipients were enrolled in this study. Outcomes were compared to a matched cohort. Data are presented in Table 1. 22 of the recipients were among the Diagnosis Group D, 2 each were in Diagnosis Groups B and C, and I in the Diagnosis group A. 19 of the 27 recipients underwent double lung transplantation. Mean ischemic allograft time was significantly higher in the study cohort (335 vs 245 min), although there was no difference in adverse outcomes when compared to a conventionally managed cohort. For lung transplant recipients whose donor cross clamp is scheduled after 1:30 AM, the recipient operation can be safely delayed until 6:30 AM, with acceptable short-term outcomes. In experienced lung transplant centers, adoption of such policy may lead to alternative workflow and improved coverage schedule. [ABSTRACT FROM AUTHOR]