Predictors of donation after circulatory death lung utilization and allograft survival

Background: Understanding donor factors associated with successful lung transplantation (LTx) following donation after circulatory death (DCD) is important in optimizing donor management. In this study, we examined critical care and ventilatory factors associated with DCD LTx and allograft survival using a unique detailed donor management database.

Methods: The Donor Management Goals national registry was queried for DCD donors between January 2016 and July 2023. The primary outcomes were DCD lung utilization and allograft survival. Multivariable modeling was used to assess factors associated with DCD LTx and allograft survival.

Results: A total of 3,394 donors met inclusion criteria and were included. Transplantation occurred in 202 (6.0%) cases with 85.6% 1-year survival. DCD LTx was more likely to occur following cerebrovascular accidents compared to anoxia and from donors who achieved a targeted PaO₂/FiO₂ (P/F) ratio at the time of organ allocation. Donor factors associated with decreased likelihood of LTx included increasing age, increasing INR, height greater than 168 cm, increasing hematocrit, and higher positive end-expiratory pressure (PEEP) at the time of organ allocation. Donor treatment with steroids and controlled mandatory ventilation, were associated with increased likelihood of graft failure at one year.

Conclusions: Successful DCD LTx associates with potentially modifiable donor parameters, including targeted P/F ratio, PEEP, INR, and hematocrit. Additionally, careful consideration of steroid use and ventilator settings may be important for improving long-term graft function. These modifiable factors may inform strategies to increase DCD LTx and improve survival.