Outcomes of Donation After Circulatory Death Lung Transplantation in the United States Based on Procurement Strategies: A United Network for Organ Sharing Analysis

BACKGROUND: Donation after circulatory death (DCD) is increasingly utilized to expand the donor pool. Within DCD, direct procurement and perfusion (DPP) and thoracoabdominal normothermic regional perfusion (TA-NRP) have emerged as distinct procurement strategies. Yet, outcomes remain unclear especially in combination with ex vivo lung perfusion (EVLP). METHODS: The United Network for Organ Sharing database was queried for adult lung transplants performed between December 2019 and March 2025. Recipients were stratified as donation after brain death (DBD), DCD DPP, or DCD TA-NRP. Propensity score matching was performed for DBD versus DCD, DBD versus DPP, DBD versus TA-NRP, and DPP versus TA-NRP comparisons. Additional analyses included DBD versus DCD EVLP subgroups. Outcomes included perioperative morbidity, primary graft dysfunction grade 3 (PGD3), and survival. RESULTS: DCD recipients demonstrated increased perioperative morbidity including longer hospitalization (22 versus 19 d, P < 0.001), greater postoperative ECMO use (15.2% versus 8.1%, P < 0.001), and higher PGD3 incidence (25.6% versus 15.6%, P < 0.001) compared with DBD, though survival was similar (P = 0.74). TA-NRP and DPP lungs had comparable outcomes, with TA-NRP showing slightly lower perioperative morbidity. Among EVLP recipients, DCD EVLP lungs were associated with longer hospitalization (26 versus 20 d, P < 0.001), higher ECMO use (19.2% versus 10.1%, P = 0.004), and a trend toward lower survival, though not statistically significant. CONCLUSIONS: DCD lungs yield survival comparable to DBD despite greater perioperative morbidity. NRP procurement may mitigate morbidity relative to DPP. Incorporating NRP into DCD practice may enhance lung utilization while maintaining acceptable outcomes.