Abstract
OBJECTIVE: Single-lung transplantation (SLT) traditionally has inferior survival compared with bilateral-lung transplantation (BLT), raising concerns regarding its use. However, with the advent of donation after circulatory death (DCD), contemporary outcomes warrant reassessment. This study evaluates survival outcomes after SLT and BLT in the modern era, focusing specifically on the impact of DCD. METHODS: We conducted a retrospective cohort analysis of adult lung transplants performed from 2018 to 2024 using the United Network for Organ Sharing database. Propensity score matching was applied to balance recipient and donor characteristics between SLT and BLT cohorts, followed by Kaplan-Meier and multivariable Cox regression analyses. RESULTS: Among 17,802 lung transplants (3747 SLT and 14,055 BLT), propensity matching yielded 3528 matched pairs. SLT recipients had significantly inferior long-term survival compared with BLT (adjusted hazard ratio [aHR], 1.35; 95% confidence interval [CI], 1.22-1.51; P < .001). However, when evaluating only DCD recipients, no significant survival differences emerged between SLT and BLT (aHR, 1.03; 95% CI, 0.68-1.5; P = .886). Notably, DCD SLT recipients demonstrated significantly better survival compared with donation after brain death SLT recipients (aHR, 1.48; 95% CI, 1.0-2.1; P = .03), despite higher rates of early graft dysfunction. CONCLUSIONS: Although BLT is generally associated with superior survival outcomes compared with SLT, our contemporary analysis found that DCD SLT outcomes were comparable with DCD BLT and more favorable than donation after brain death SLT. These findings suggest that DCD lungs may be a viable option for single lung transplantation and highlight the potential role of DCD in expanding the donor pool. Further research is warranted to better understand long-term outcomes and optimize recipient selection for DCD SLT.