Strategies to address donor organ shortages in lung transplantation

PURPOSE OF REVIEW: Lung transplantation remains limited by donor organ scarcity. This review summarizes recent strategies with the direct potential to expand lung availability, including 10°C hypothermic preservation, donation after circulatory death (DCD), ex vivo lung perfusion (EVLP), and expanded utilization of elderly donors. RECENT FINDINGS: Clinical translation of 10°C static preservation has enabled prolonged storage, including preservation for up to 24 h without clear adverse short- or intermediate-term consequences, and the prospect of semi-elective transplantation. Contemporary evidence supports broader use of DCD lungs, particularly controlled DCD, with reassuring long-term outcomes despite small differences in early risk in some cohorts; uncontrolled DCD remains promising in highly organized EVLP-based programs, whereas thoracoabdominal normothermic regional perfusion requires further prospective evaluation. EVLP continues to increase utilization of marginal lungs, and the largest single-center series reported outcomes comparable to conventional transplantation. In parallel, carefully selected septuagenarian and even octo-/nonagenarian donors have demonstrated encouraging short- and long-term clinical outcomes. SUMMARY: Donor shortage in lung transplantation can be mitigated by combining logistics-extending preservation strategies, broader donor pathways, advanced graft assessment, and careful expansion of donor acceptance criteria. Standardized, prospective, multicenter clinical trials are still frequently lacking and represent an area for future improvement.