BACKGROUND Donation after circulatory death (DCD) and ex-vivo lung perfusion (EVLP) have been adopted to expand the donor pool in lung transplantation, but outcomes data have been conflicting. This study explores outcomes of DCD and EVLP lung transplantation in the modern era. METHODS The United Network for Organ Sharing database was queried for adult lung transplants from January 1, 2015 to March 1, 2023. Loss to follow-up, multiorgan, and prior lung transplants were excluded. DCD versus donation after brain death (DBD) lung transplants were compared with subgroup analysis +/- EVLP. Outcomes were survival and postoperative complications. RESULTS The study included 1,103 DCD (221 with EVLP and 882 without) and 17,973 DBD lung transplants (524 with EVLP and 17,449 without). Median follow-up was 3 years. DCD donors were less likely to be CDC high risk (19.3% vs 24.1%, p < 0.001), have purulence on bronchoscopy (13.3% vs 18.3%, p < 0.001), or infiltrates on chest X-ray (66.7% vs 67.8%, p = 0.013). EVLP was more likely to be used for DCD transplants (20.0% vs 2.9%, p < 0.001). After transplant, DCD recipients were more likely to be reintubated (24.3% vs 18.5%, p < 0.001) and require ECMO within 72 hours (14.9% vs 7.8%, p < 0.001), and DCD donation was an independent risk factor for these complications on multivariable logistic regression. Overall survival did not differ significantly between DCD and DBD transplants on adjusted survival analysis in the early or modern era (p = 0.774 and p = 0.468, respectively). On subgroup analysis, the DCD+EVLP cohort had significantly worse survival in the modern era, which remained significant after adjusting for donor and recipient factors (p = 0.005). EVLP was an independent risk factor for graft failure in the DCD cohort (hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.00-1.77, p = 0.047) but did not significantly affect DBD graft survival (p = 0.870). Risk factors for graft failure and mortality in the DCD+EVLP cohort included pulmonary hypertension (HR 77.5, 95% CI 6.15-979, p < 0.001), transfusion before transplant (HR 2.60, 95% CI 1.07-6.31, p = 0.035), elevated creatinine (HR 2.82, 95% CI 1.34-5.90, p = 0.006), and higher allocation score (HR 1.02, 95% CI 1.00-1.04, p = 0.017) CONCLUSIONS: Study findings suggest increased risks of mortality and perioperative complications following transplantation with DCD lungs that have undergone EVLP. DCD lung transplantation without EVLP confers equivalent survival but with some increase in perioperative complications. Further investigation and careful recipient selection are warranted to optimize the use of these extended criteria donors in the modern era.

中文翻译：

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循环死亡 （DCD） 和离体肺灌注 （EVLP） 肺移植后捐献的结果。


背景 循环死亡 （DCD） 和离体肺灌注 （EVLP） 后捐献已被用于扩大肺移植的供体库，但结果数据一直相互矛盾。本研究探讨了现代 DCD 和 EVLP 肺移植的结果。方法 查询 2015 年 1 月 1 日至 2023 年 3 月 1 日的器官共享联合网络数据库的成人肺移植。排除失访、多器官和既往肺移植。将 DCD 与脑死亡 （DBD） 肺移植后捐献与亚组分析 +/- EVLP 进行比较。结局是生存率和术后并发症。结果该研究包括 1,103 例 DCD （221 例有 EVLP，882 例无）和 17,973 例 DBD 肺移植 （524 例有 EVLP，17,449 例无）。中位随访时间为 3 年。DCD 供体不太可能是 CDC 高风险 （19.3% 对 24.1%，p < 0.001），支气管镜检查有脓性 （13.3% 对 18.3%，p < 0.001），或胸部 X 光片浸润 （66.7% 对 67.8%，p = 0.013）。EVLP 更可能用于 DCD 移植 （20.0% vs 2.9%，p < 0.001）。移植后，DCD 受者更有可能再次插管 （24.3% vs 18.5%，p < 0.001） 并在 72 小时内需要 ECMO （14.9% vs 7.8%，p < 0.001），并且 DCD 捐赠是多变量 logistic 回归中这些并发症的独立危险因素。在早期或现代的调整生存分析中，DCD 和 DBD 移植的总生存期没有显著差异 （分别为 p = 0.774 和 p = 0.468）。在亚组分析中，DCD+EVLP 队列在现代的生存率明显较差，在调整供体和受体因素后仍然显着 （p = 0.005）。 EVLP 是 DCD 队列中移植物失败的独立危险因素 （风险比 [HR] 1.33,95% 置信区间 [CI] 1.00-1.77，p = 0.047），但未显著影响 DBD 移植物存活率 （p = 0.870）。DCD+EVLP 队列中移植失败和死亡的危险因素包括肺动脉高压 （HR 77.5,95% CI 6.15-979，p < 0.001）、移植前输血 （HR 2.60,95% CI 1.07-6.31，p = 0.035）、肌酐升高 （HR 2.82,95% CI 1.34-5.90，p = 0.006） 和较高的分配评分 （HR 1.02,95% CI 1.00-1.04，p = 0.017） 结论： 研究结果表明，接受 DCD 的肺移植后死亡和围手术期并发症风险增加EVLP 的。无 EVLP 的 DCD 肺移植可提供等效的生存率，但围手术期并发症有所增加。需要进一步调查和仔细选择受体，以优化现代对这些扩展标准供体的使用。