Abstract / Summary
Background: Uptake of donation after circulatory death (DCD) in lung transplantation is limited by concerns surrounding ischemic injury. This study aimed to assess the effects of prolonged donor agonal time during DCD procurement on recipient outcomes. Methods: One thousand three hundred five DCD lung recipients from January 2016 to June 2024 from the Scientific Registry of Transplant Recipients were analyzed. Donor agonal time was measured from the start of the agonal phase (SpO 2 <80% or systolic blood pressure<80 mmHg) to the declaration of death. A nonlinear 3-knot spline was fit for agonal time against composite outcomes of impaired allograft oxygenation (PaO 2 /FiO 2 ≤200 or ECMO support at 72 hours post-transplant) and prolonged respiratory recovery (intubation or iNO requirement at 72 hours post-transplant, intubation for ≥5 days, or reintubation). Cohorts of recipients from “long-agonal” ( n = 837) and “short-agonal” ( n = 468) donors were defined by an agonal time threshold of 15 minutes. Results: Splines of agonal time against either composite outcome were statistically insignificant after multivariate correction. A trend towards impaired allograft oxygenation was observed with increased agonal time until an inflection point at 13.9 minutes. In the cohort analysis, long-agonal recipients displayed higher rates of PaO 2 /FiO 2 ≤200 (24% vs 17%, p = 0.017) at 72 h post-transplant and higher rates of long-term graft failure ( p = 0.026) and retransplantation ( p = 0.01), but equivalent overall survival ( p = 0.087). Conclusions: Prolonged DCD donor agonal time is not significantly associated with impaired post-transplant recovery following DCD lung transplantation. Although prolonged agonal time was associated with increased graft failure, the exact contribution of donor agonal time to this outcome remains unclear.