Outcomes of lung transplantation at a Canadian center using donors declined in the United States



      Donor lungs from the United States can be offered by US organ procurement organizations to Canada if no American centers accept them. The purpose of this study is to evaluate outcomes of patients undergoing transplant at a single center in Canada using declined lungs from the United States and to compare these outcomes to patients receiving lungs from Canadian donors.


      A single-center retrospective review of recipients receiving lung transplantation between January 2009 and October 2019 was performed. An Organ Procurement and Transplantation Network standard transplant analysis and research-limited dataset as of August 17, 2021, was provided by the United Network for Organ Sharing. De-identified patient-level data were extracted from the standard transplant analysis and research file to identify lung offers made by US organ procurement organizations, declined by US lung centers, and transplanted by the University Health Network within the study time frame. We divided the analysis into 2 groups: recipients receiving donor lungs from Canada and recipients receiving donor lungs from the United States. Donor and recipient characteristics between the 2 groups were compared. Primary end point was proportional survival over a 10-year period. Secondary end points included 30-day mortality, intensive care unit and hospital length of stay, severe primary graft dysfunction, and incidence of chronic lung allograft dysfunction.


      During the study period, 1424 lung transplants were performed at our center. Of these, 124 (8.7%) were performed using donors from the United States. The incidence of transplants using US donors increased from 5% (5 out of 102) in 2009 to 15% (30 out of 200) in 2018. US donors were younger (aged 41 vs 47 years; P = .004), less likely to be from donors after cardiac death (9.6% vs 20%; P = .008), had higher use of ex vivo lung perfusion (EVLP, 46% vs 27%; P = .0002), and higher incidence of positive nucleic acid test for hepatitis C (16% vs 0.7%; P = .0001). Although the incidence of EVLP utilization was higher in the US lungs versus Canada lungs, more than half of US lungs (54%) proceeded directly to transplantation. Similar short- and long-term outcomes were observed between the 2 groups, including overall survival (hazard ratio, 1.12; 95% CI, 0.85-1.47; P = .40)


      Lung transplantation using donor lungs declined by multiple centers in the United States resulted in similar short- and long-term outcomes compared with donor lungs offered in Canada.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      CLAD (chronic lung allograft dysfunction), DCD (donation after cardiocirculatory death), EVLP (ex vivo lung perfusion), ECMO (extra-corporeal membrane oxygenation), Fio2 (inspired oxygen fraction), HCV (hepatitis C virus), ICU (intensive care unit), LAS (lung allocation score), OPO (organ procurement organization), OPTN (Organ Procurement and Transplantation Network), PGD (primary graft dysfunction)
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        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          The optimal system for equitable and just donor lung allocation remains debatable. Canada and the United States share a common border and similar levels of advanced health care. In addition, US and Canadian physicians have a long history of collaboration in the field of transplantation, with many cross-national–trained physicians heading some of the best thoracic transplant programs in the world.
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      • Commentary: A sobering reality: Donor lungs declined in the United States transplanted successfully in Canada
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          Cypel and colleagues1 present their experience with lung transplantation using donor lungs that were declined by centers in the United States and then offered to their center in Ontario, Canada. Over a 10-year period (from 2009 to 2019), 124 patients underwent lung transplantation using these organs. During the same period, they performed 1300 transplants using lungs from direct offers from Canadian centers. The percentage of transplanted patients with lungs from an American donor increased from 5% to 15% over this time.
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