Beyond boundaries: Redefining the donor frontier in pediatric lung transplantation

Abstract

Background: Lung transplantation remains the optimal treatment for children with end-stage lung disease, yet donor organ shortage represents the greatest obstacle to transplantation. In 2023, only 31 pediatric lung transplants were performed in the United States, with 9% of recovered lungs ultimately not transplanted. Pediatric waitlist mortality has increased, particularly for patients under one year of age, necessitating innovative strategies to expand the donor pool.

Methods: This review examines emerging strategies to combat organ shortage in pediatric lung transplantation, including extended criteria donors, deceased cardiac death (DCD) organ donation, ex-vivo lung perfusion (EVLP), graft size reduction techniques, living donor lobar transplantation, and utilization of hepatitis C and HIV-positive donor organs. We analyzed current literature and clinical outcomes data to assess the feasibility and safety of these approaches in pediatric populations.

Results: Extended criteria donors now account for 80% of lung transplants without compromising short- and mid-term pediatric outcomes. DCD lung transplantation demonstrates comparable survival rates to brain-dead donors, with only 14 DCD organs used in pediatric programs between 2004-2022. EVLP shows promise in preserving organ viability and reducing primary graft dysfunction. Hepatitis C-positive donors demonstrate excellent outcomes with direct-acting antiviral therapy in adult patients, but scant literature is available in the pediatric population. Reduced-size grafts and living donor procedures offer solutions for size-mismatched recipients.

Conclusions: Multiple innovative strategies show potential for expanding the pediatric lung donor pool. While adult data demonstrates safety and efficacy, pediatric-specific research remains limited. Continued scientific inquiry, active donor management protocols, and interdisciplinary cooperation are essential to safely implement these approaches and improve access to life-saving transplantation for children.

Keywords: EVLP; deceased after cardiac death; ex vivo lung perfusion; living donor lobar lung transplant; lung transplant; organ donor; pediatric.