Lung Transplantation From Donation After Circulatory Death: United States and Single-Center Experience

Villavicencio MA¹, Axtell AL², Spencer PJ², Heng EE³, Kilmarx S³, Dalpozzal N⁴, Funamoto M³, Roy N³, Osho A³, Melnitchouk S², D’Alessandro DA², Tolis G², Astor T⁵. (Boston)

Ann Thorac Surg. 2018 Dec;106(6):1619-1627. doi: 10.1016/j.athoracsur.2018.07.024

BACKGROUND:
Lung transplants from donation after circulatory death (DCD) have been scarcely used in the United States. Concerns about the warm ischemic injury, resource mal-utilization due to the uncertain timing of death, and public scrutiny may be some factors involved.

METHODS:
Survival for recipients of a donation after brain death (DBD) versus DCD was analyzed by using the United Network for Organ Sharing and our institutional database. A propensity-matching and Cox regression analysis was performed for 25 characteristics. Primary graft dysfunction metrics were compared.

RESULTS:
A total of 389 of 20,905 lung transplantations (2%) were performed by using DCDs in the United States, and 15 of 128 (12%) at our institution. Five and 10-year survival for DBDs was 55% and 30% and 59% and 33% for DCDs, respectively. Propensity-matched analysis of 311 DBD/DCD pairs did not demonstrate any difference in survival. On Cox regression, DCD was not associated with impaired survival. Male sex, Karnofsky class greater than 50, double lung transplantation, and transplantation year were predictors of improved survival. Age, creatinine, pulmonary fibrosis, retransplantation, extracorporeal membrane oxygenation, allocation score, and donor age were predictors of worse survival. Primary graft dysfunction at time 0 was worse for recipients of DCDs (p = 0.005) but equivalent at 24, 48, and 72 hours.

CONCLUSIONS:
DCD lung transplants remain underused in the United States. Nevertheless, survival is similar to DBD. Primary graft dysfunction metrics for DCDs are worse than DBDs on intensive care arrival but improved subsequently.