Abstract
BACKGROUND: Lungs from older donation after circulatory death (DCD) donors are underutilized; however, these organs may represent an opportunity to expand the donor pool. Herein, we evaluated utilization and outcomes of lung transplants using lungs from older DCD donors. METHODS: Using national data from 2016 to 2024, we identified all adult DCD donors and corresponding isolated lung transplant recipients. Multivariable logistic regression was used to identify predictors of lung utilization. Kaplan-Meier and Cox proportional hazards methods were used to compare graft survival between recipients of lungs from DCD donors <55 and ≥55 years. RESULTS: Among 10,769 older (age ≥ 55) DCD donors identified, lungs were transplanted from only 302 (2.8%) with significant organ procurement organization- and center-level variation in use. Just one center exceeded 50 transplants using older DCD donors over the study period. Utilization increased over time (7 cases in 2016 vs 111 in 2024; p < 0.001). Ex-vivo lung perfusion (odds ratio 5.93) and higher PaO₂/FiO₂ ratio (odds ratio 1.33 per 50-point increase) were independently associated with transplantation of older DCD donor lungs. One- and three-year graft survival were similar between age groups; older donor age was not associated with increased risk of graft failure in adjusted models. CONCLUSIONS: Lungs from older DCD donors remain underutilized despite comparable outcomes. Their use is highly concentrated among a small number of centers and organ procurement organizations, suggesting that local behaviors and infrastructure strongly influence disposition. Broader adoption of ex-vivo lung perfusion and strategic recipient matching may support safe expansion of this untapped donor pool.