Outcomes of lung transplantation from asphyxiation donors: reassessing hypoxic injury and implications for donation after circulatory death

Abstract Objectives With persistent donor shortages limiting lung transplantation (LT), optimizing the use of extended-criteria donors is essential. Asphyxiation (AXP) and donation after circulatory death (DCD) donors both experience hypoxic–ischemic injury, raising concern for graft performance. We evaluated the long-term outcomes of AXP donor LT and the effect of ex-vivo lung perfusion (EVLP) on survival. Methods Adult recipients (≥18 years) of primary LT (2014–2024) in the United Network for Organ Sharing registry were stratified by donor cause of death: AXP vs non-AXP. Survival was estimated by Kaplan–Meier analysis, and multivariable Cox regression identified factors associated with mortality. Subgroup analyses examined EVLP and DCD versus donation after brain death (DBD) cohorts. Results Among 26,334 LT recipients, 1,406 (5.3%) received AXP donor lungs. AXP donors were more frequently DCD (9.5% vs. 6%, p0.001). Ten-year recipient (25.2% vs 27.4%; p=0.67) and graft (24.1% vs 26.8%; p=0.72) survival were comparable, and AXP status was not independently associated with mortality after adjusting for allocation era (HR 1.01, 95% CI 0.91—1.11, p=0.908). However, EVLP use in AXP lungs correlated with decreased 3-year survival (55.3% vs. 74.1%; p=0.035). Sensitivity analyses demonstrated significant differences among the four donor subgroups (DCD-AXP, DCD non-AXP, DBD-AXP, DBD non-AXP) on overall comparison (p=0.008), with DCD-AXP recipients exhibiting numerically highest 5-year survival rates. Conclusions AXP donor lungs provide comparable long-term outcomes, and DCD-AXP grafts do not appear to confer inferior survival. The interaction between AXP and EVLP use warrants further study to refine donor reconditioning strategies.