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OBM Transplantation

(ISSN 2577-5820)

OBM Transplantation (ISSN 2577-5820) is an international peer-reviewed Open Access journal published quarterly online by LIDSEN Publishing Inc., which covers all evidence-based scientific studies related to transplantation, including: transplantation procedures and the maintenance of transplanted tissues or organs; assimilation of grafted tissue and the reconstitution of removed organs or parts of organs; transplantation of heart, lung, kidney, liver, pancreatic islets and bone marrow, etc. Areas related to clinical and experimental transplantation are also of interest.

OBM Transplantation is committed to rapid review and publication, and we aim at serving the international transplant community with high accessibility as well as relevant and high quality content.

The journal publishes all types of articles in English. There is no restriction on the length of the papers. We encourage authors to be concise but present their results in as much detail as necessary, as reviewers are expected to emphasize scientific rigor and reproducibility.

 
 

Publication Speed (median values for papers published in 2024): Submission to First Decision: 6.7 weeks; Submission to Acceptance: 14.4 weeks; Acceptance to Publication: 4 days (1-2 days of FREE language polishing included)

 
 
Current Issue: 2026  Archive: 2025 2024 2023 2022 2021 2020 2019 2018 2017
Open Access Review

Optimizing Donor Management Strategies for DCD Lung Procurement

Chawannuch Ruaengsri 1, *, Miguel Alvarez-Cortes 2, Marc Leon 1, Manuel Quiroz-Flores 1, Masafumi Shibata 1, Yasuhiro Shudo 1

  1. Stanford University, 450 Jane Stanford Way, Stanford, CA 94305, USA

  2. University of Puerto Rico School of Medicine, San Juan, PR 365067, USA

* Correspondence: Chawannuch Ruaengsri 

Academic Editor: Luca Brazzi

Special Issue: Organ Preservation and Distribution

Received: June 30, 2025 | Accepted: December 15, 2025 | Published: December 30, 2025

OBM Transplantation 2025, Volume 9, Issue 4, doi:10.21926/obm.transplant.2504261

Recommended citation: Ruaengsri C, Alvarez-Cortes M, Leon M, Quiroz-Flores M, Shibata M, Shudo Y. Optimizing Donor Management Strategies for DCD Lung Procurement. OBM Transplantation 2025; 9(4): 261; doi:10.21926/obm.transplant.2504261.

© 2025 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

Donation after circulatory death (DCD) offers a vital strategy to expand the donor lung pool; however, DCD lungs are uniquely susceptible to warm ischemic injury during procurement. This chapter reviews evidence-based and emerging donor management strategies aimed at mitigating ischemic damage and optimizing the suitability of DCD lungs for transplantation, encompassing hemodynamic and ventilatory optimization, bronchoscopic clearance, targeted pharmacological interventions, and strategies to minimize transfusion requirements. Remote monitoring holds promise for further improving lung quality. Optimizing donor management strategies is critical to maximizing the utilization of DCD lungs, and future research should focus on refining existing protocols, evaluating new technologies, and addressing ethical considerations to ensure equitable access to lung transplant.

Keywords

Lung transplantation; donation after circulatory death; organ preservation; ex-vivo lung perfusion

1. Introduction

Lung transplantation offers a life-saving therapy for patients with end-stage lung disease. However, the persistent shortage of donor lungs remains a major challenge, prompting the transplant community to explore the use of lungs from donation after circulatory death (DCD). This strategy aims to expand the donor pool, potentially increasing donor availability by up to 30%, according to the American College of Chest Physicians [1]. While DCD offers a valuable opportunity to expand the donor pool, DCD lungs are particularly vulnerable to warm ischemic injury, which can significantly compromise their suitability for transplantation [2]. Effective donor management strategies are, therefore, critical to mitigating ischemic damage and maximizing the utilization of DCD lungs [3]. This chapter will review evidence-based and emerging strategies for optimizing donor management in DCD lung procurement, encompassing hemodynamic and ventilatory support, bronchoscopic clearance, pharmacological interventions, and strategies to minimize transfusion requirements, ultimately aiming to improve the quality and availability of DCD lungs for transplantation.

2. The Unique Challenges of DCD Lung Donor Management

DCD lung procurement presents distinct challenges compared to donation after brain death (DBD), primarily related to the period of warm ischemia that occurs following circulatory arrest. This warm ischemia triggers a cascade of pathological events that can compromise lung viability and increase the risk of primary graft dysfunction (PGD) after transplantation [4]. Effective donor management strategies in DCD lung procurement must, therefore, address these unique challenges.

2.1 Controlled and Uncontrolled DCD in Lung Transplantation

Donation after circulatory death (DCD) comprises 2 primary pathways, controlled DCD (cDCD) and uncontrolled (uDCD) [5]. cDCD involves a planned withdrawal of life support in a controlled setting, typically post-anesthesia care unit (PACU), operating room (OR), or intensive care unit (ICU) [5]. This planed and controlled environment allows for optimized donor management, a predictable and often shorter warm ischemic time (WIT), and planned surgical team coordination. Lungs retrieved via cDCD generally experience less ischemic injury making them more readily suitable for transplantation or with normothermic regional perfusion (NRP) to further minimize organ ischemia [6]. On the other hand, uDCD occurs following an unanticipated cardiac arrest, often outside hospital or in an emergency room where withdrawal of support is not performed. The unpredictable situation and potentially prolonged period of warm ischemia in uDCD donors present significant challenges to organ viability. Lung procured from uDCD often incur more degree of ischemic damage, necessitating advanced preservation techniques such as ex-vivo lung perfusion (EVLP), for organ assessment, rehabilitation, and improved lung quality before transplantation [5,6].

3. Physiological Changes Following Circulatory Arrest

3.1 Warm Ischemia and Its Impact on Lung Function

Following circulatory arrest, the lungs are deprived of oxygen and nutrients, leading to a rapid decline in cellular function. The duration and severity of this warm ischemia time are critical determinants of lung injury [7]. Warm ischemia leads to cellular swelling, mitochondrial dysfunction, and the release of reactive oxygen species (ROS), all of which contribute to tissue damage [8]. The longer the warm ischemia time, the greater the degree of lung injury and the lower the likelihood of successful transplantation [9].

3.2 Endothelial Damage, Pulmonary Edema, and Impaired Gas Exchange

Warm ischemia-induced injury primarily targets the pulmonary endothelium, the delicate lining of the lung capillaries. Endothelial damage increases permeability, leading to fluid leakage into the interstitial space and alveolar spaces, resulting in pulmonary edema [10]. This edema impairs gas exchange, reducing the PaO2/FiO2 ratio and increasing the risk of PGD [11].

4. Coagulopathy and Its Impact on Lung Transplantation

4.1 Bleeding

Following circulatory arrest and cessation of antemortem systemic heparinization, donors may develop a consumptive coagulopathy with resultant increased bleeding risk at the time of surgical organ recovery. This risk is especially relevant in donation after circulatory death (DCD), where the absence of antemortem heparin may predispose to microvascular thrombosis and subsequent consumptive coagulopathy, leading to increased intraoperative bleeding risk [12,13].

4.2 Transfusion Needs

As a consequence, many patients may then need blood transfusion during the procedure. Increased transfusion requirements in this context heighten the risk of transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO), which can directly lead to PGD and increase the risk of early graft failure and death [14,15].

5. Time Constraints and Logistical Considerations

5.1 Expedited Decision-Making

The time-sensitive nature of DCD lung procurement necessitates rapid assessment and decision-making regarding donor suitability. Transplant teams must quickly assess donor suitability, focusing on the risk of lung injury from aspiration, hypoxemia, hypotension, or infection, and must balance these risks against the mortality risk of prolonged wait times for ideal donors [1,11].

5.2 Coordination and Communication

Successful DCD lung procurement is highly dependent on seamless coordination and communication among the donor hospital, organ procurement organization (OPO), and transplant center [1]. This includes timely communication of donor information, efficient organ recovery and transport, and prompt preparation of the recipient for transplantation. These steps are critical to maintain organ viability and maximize the likelihood of successful transplantation [16].

6. Key Elements of Donor Management

Effective donor management in DCD lung procurement requires a multifaceted approach, encompassing meticulous attention to hemodynamic and ventilatory support, aggressive bronchoscopic clearance, and judicious use of pharmacological interventions [1,2]. The overarching goal is to minimize warm ischemic injury, prevent secondary lung damage, and optimize lung viability for transplantation [17].

6.1 Hemodynamic Management

6.1.1 Target Blood Pressure and Volume Status

Maintaining adequate blood pressure is crucial to ensure sufficient perfusion of the donor lungs during the pre-procurement period. However, excessive fluid administration can exacerbate pulmonary edema, increasing the risk of PGD [10]. The optimal strategy involves a balanced approach (Figure 1), carefully titrating intravenous fluids to maintain adequate perfusion while avoiding fluid overload [18]. Close monitoring of central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) can be helpful in guiding fluid management. A mean arterial pressure (MAP) of 60-80 mmHg is generally considered an appropriate target [19].

Click to view original image

Figure 1 Suggested monitoring and interventions at the different stages of shock. Therapeutic options (yellow in blue rectangles) and monitoring techniques and goals at the different stages of septic shock. MAP mean arterial pressure, CRT capillary refill time, echo echocardiography, DAP diastolic blood pressure - A plea for personalization of the hemodynamic management of septic shock. Crit Care 26, 372 (2022). https://doi.org/10.1186/s13054-022-04255-y [20].

6.1.2 Use of Vasopressors and Inotropes

Vasopressors, such as norepinephrine or vasopressin, may be necessary to maintain adequate blood pressure in hypotensive donors. Inotropic agents, such as dobutamine, can be used to improve cardiac output and enhance lung perfusion [21,22]. However, the use of these agents should be carefully monitored to avoid excessive vasoconstriction, which can compromise organ perfusion, or excessive inotropy, which may increase myocardial oxygen demand and risk ischemia, particularly in the context of lung donation where pulmonary edema and right heart strain are concerns [23].

6.1.3 Avoiding Fluid Overload

Fluid overload is a major risk factor for pulmonary edema and PGD in DCD lung recipients [19]. Strategies to minimize fluid overload include careful monitoring of fluid balance, judicious use of diuretics, and, in some cases, the use of ultrafiltration. It can be challenging to distinguish pulmonary edema due to lung injury from that due to aggressive fluid resuscitation. Therefore, a strategy targeting euvolemia or even mild hypovolemia may be a better approach to DCD lung management [11,24].

6.2 Ventilatory Management

6.2.1 Lung Protective Ventilation

Lung-protective ventilation strategies are essential to minimize ventilator-induced lung injury (VILI) in DCD donors. This involves using low tidal volumes (6–8 mL/kg predicted body weight), limiting plateau pressures to <30 cm H2O, and employing appropriate levels of positive end-expiratory pressure (PEEP), typically in the range of 8–10 cm H2O [25].

6.2.2 Optimal PEEP and Tidal Volume Strategies

The optimal PEEP level should be individualized based on the donor's lung mechanics and oxygenation. Higher PEEP levels may be necessary to maintain alveolar recruitment and improve oxygenation, but excessive PEEP can lead to overdistension and VILI [26,27]. Similarly, tidal volumes should be carefully adjusted to balance the need for adequate ventilation with the risk of barotrauma [28].

6.2.3 Recruitment Maneuvers

Recruitment maneuvers, such as sustained inflation or incremental PEEP increases, can be used to open collapsed alveoli and improve oxygenation. However, these maneuvers should be performed cautiously, as they can also cause barotrauma (Figure 2) or hemodynamic instability [29].

Click to view original image

Figure 2 Lung Compliance Curve. Plotting the pressure versus volume of the lung during incremental inflation yields the compliance curve. The sigmoid shape shows that lung compliance is best in the middle zone of a normal functioning lung. Atelectasis and overdistention are associated with a flattening of the curve, indicating greater pressure is required to produce the same tidal volume. Two equal tidal volumes are shown. The tidal volume delivered in the zone of good compliance requires less pressure than the same volume delivered in the zone of atelectasis. Ventilating the lung when compliance is reduced can result in injury. From: Walton, J. J. (2015). Advanced ventilation management. Surgery (Oxford), 33(10), 485-490 [30].

6.3 Bronchoscopic Management

6.3.1 Secretion Clearance and Prevention of Aspiration

Aggressive bronchoscopic clearance of secretions is essential to prevent atelectasis and pneumonia. Frequent suctioning and bronchoalveolar lavage (BAL) can help remove secretions and cellular debris from the airways, improving lung hygiene and potentially improving the PaO2/FiO2 ratio by enhancing gas exchange [31].

6.3.2 Strategies to Prevent Ventilator-Associated Pneumonia (VAP)

VAP is a common complication in mechanically ventilated patients and can significantly compromise lung function [32]. Strategies to prevent VAP include meticulous oral care, elevation of the head of the bed, and the use of closed suction systems [28,33]. This management is essential to prevent lung atelectasis and pneumonia.

6.4 Pharmacological Interventions

6.4.1 Use of Steroids

Corticosteroids, such as methylprednisolone, are often administered to DCD donors to reduce proinflammatory cytokine release, limit pulmonary and myocardial edema, and improve organ function post-transplant. Steroids can help stabilize the pulmonary endothelium, reduce pulmonary edema, and improve oxygenation [34].

6.4.2 Antioxidants (e.g., N-Acetylcysteine)

Antioxidants, such as N-acetylcysteine (NAC), can help mitigate oxidative stress and reduce lung injury in DCD donors. NAC scavenges free radicals and promotes glutathione synthesis, protecting lung cells from oxidative damage. There are a number of new antioxidants in production that have shown great results in the cell models, but these remain investigational and are not part of established protocols [3,35].

6.4.3 Beta-Agonists (e.g., Albuterol)

Beta-agonists, such as albuterol, can help dilate the airways and improve airflow, reducing airway resistance and improving gas exchange [36].

6.4.4 Antibiotics

The use of broad-spectrum antibiotics for a limited amount of time can be highly beneficial, and is standard practice in DCD donor management. However, there has been much debate and variability in practice. It has been left on the users on what their expertise and skill set shows to improve results [37].

6.4.5 Emerging Therapeutics (e.g., Mesenchymal Stem Cells)

Mesenchymal stem cells (MSCs) are being investigated as a potential therapy to reduce lung injury and promote lung repair in DCD donors. MSCs have anti-inflammatory, immunomodulatory, and regenerative properties that may help protect the lungs from ischemic damage [1,3,4,35].

7. Strategies to Minimize Warm Ischemic Time

Minimizing warm ischemia time is arguably the most critical factor in optimizing DCD lung viability. The longer the period of warm ischemia, the greater the extent of irreversible lung damage [7,8,9]. Therefore, all efforts should be directed toward expediting the procurement process while maintaining meticulous surgical technique and ensuring donor and recipient safety.

7.1 Expedited Surgical Technique

  • Efficient Dissection and Cannulation: Streamlining the surgical dissection and cannulation steps is crucial to minimizing warm ischemia time [23]. This requires a well-coordinated surgical team with expertise in rapid organ recovery techniques. The use of standardized surgical checklists and protocols can help ensure that all steps are performed efficiently and without unnecessary delays [38].
  • En-Bloc Procurement: In some cases, especially DCD lung direct recovery technique combined with Abdominal NRP (A-NRP) (Figure 3). En-bloc procurement of the heart and lungs may be considered to expedite the recovery process. This involves removing the heart and lungs together as a single unit, minimizing the time spent dissecting individual structures. This approach is particularly advantageous in expediting the procurement process and preserving graft integrity, especially in donors with complex anatomy or when time is critical to optimize organ preservation and minimize ischemic time [39,40].

Click to view original image

Figure 3 Step by step schematic presentation of DCD lung direct procurement under Abdominal NRP (A-NRP). WLST, Withdrawal life sustaining therapies; NRP, normothermic regional perfusion. ECMO, extracorporeal membrane oxygenation; PA, pulmonary artery; SVC, superior vena cava; IVC, inferior vena cava. FiO2, Fraction of inspired oxygen; PEEP, Positive end expiratory pressure. - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Step-by-step-schematic-presentation-of-DCD-organ-procurement-under-NRP-WLST_fig2_380631794 [6].

7.1.1 Re-institution of Mechanical Ventilation in DCD Lung Procurement

The prompt re-institution of mechanical ventilation after the declaration of circulatory death in DCD donors is an essential strategy employed to minimize the effect of warm ischemia on lung allografts [7,41]. After circulatory arrest, the lung parenchyma rapidly depletes its oxygen reserves, leading to cellular hypoxia and the initiation of ischemic injury [7]. Typically performed by anesthesiologist or a Certified Registered Nurse Anesthetist (CRNA), immediate re-intubation and subsequent mechanical ventilation allow for early alveolar recruitment and re-oxygenation of the alveolar tissue [7]. Re-intubation and mechanical ventilation aim to prevent progressive cellular damage, reduce atelectasis that would compromise lung viability and increase the risk of primary graft dysfunction (PGD) post-transplantation [28,41].

7.1.2 Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) in DCD Lung Procurement

Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) has emerged as a strategy aiming to mitigate warm ischemic injury inherent to DCD by restoring oxygenated blood flow to entire body after the declaration of death [41,42]. For lung allografts, TA-NRP offers a critical window for real-time physiological assessment of lung function, including lung compliance and gas exchange. After weaning of TA-NRP, arterial blood gas analysis can be performed to evaluate alveolar gas exchange capabilities. To further protect the lung parenchyma during perfusion, pulmonary artery (PA) venting is frequently employed [42]. This technique helps to decompress the pulmonary circulation, reducing hydrostatic pressure and minimize the risk of pulmonary edema in the lung allograft [42]. Ongoing refinements in DCD protocols, including specific lung protective measures during perfusion, have demonstrated its feasibility and efficacy in yielding high-quality, transplantable DCD lungs [42].

7.1.3 Ex-Vivo Lung Perfusion (EVLP) in DCD Lung Procurement

Ex-vivo lung perfusion (EVLP) plays an instrumental role in optimizing DCD lung allografts. This technique provides a unique ex-vivo platform for lung assessment, reconditioning, and functional optimization of marginal DCD lung allografts that might be not suitable for transplantation [43]. By ventilating and perfusing the lungs under near physiological condition, transplant centers can evaluate the lung’s functional capacity, identify and potentially reverse damage [41]. This strategy is crucial for significantly reducing the risk of PGD, as it enables better selection of suitable grafts and allows for targeted interventions to improve graft quality before implantation [43,44]. For transplant centers and teams that do not have EVLP capabilities in-house, specialized EVLP centers serve as vital hubs, with organs often procured and transported to these dedicated facilities for lung assessment and reconditioning before eventual transplantation [45,46]. Ultimately, EVLP serves as a critical bridge, allowing for the safe expansion of the DCD donor pool and improving recipient outcomes by ensuring only the suitable allografts are transplanted [43].

7.2 Team Coordination and Communication

7.2.1 Clear Communication Protocols

Establish clear lines of communication between the donor hospital, the organ procurement organization (OPO), and the transplant center. This includes timely notification of donor declaration of death, prompt sharing of relevant donor information, and efficient coordination of organ transport logistics [47].

7.2.2 Pre-emptive Team Briefings

Conduct pre-emptive briefings with all members of the procurement team to discuss the surgical plan, anticipated challenges, and strategies to minimize delays. This ensures that everyone is on the same page and prepared to execute the procurement efficiently. For example, a pre-post study demonstrated that implementation of preoperative briefings led to a 31% reduction in unexpected delays and a 19% reduction in communication breakdowns that caused delays, with an even greater reduction in delays reported among surgeons [48].

7.2.3 Dedicated Procurement Teams

Having dedicated and experienced procurement teams can significantly reduce warm ischemia time. These teams are familiar with the specific protocols and techniques for DCD organ recovery and can work efficiently and effectively [3,23].

8. Gaps in Evidence, Future Directions

Beyond the established strategies outlined above, several novel approaches and emerging technologies hold promise for further optimizing donor management and improving DCD lung utilization.

8.1 Remote Monitoring and Telemedicine

8.1.1 Real-Time Physiological Data Transmission

The use of telemedicine allows for the transmission of real-time physiological data (e.g., blood pressure, oxygen saturation, ventilator settings) from the donor hospital to the transplant center. This enables remote monitoring of the donor’s condition and facilitates timely adjustments to management strategies [49,50,51].

8.1.2 Remote Consultation with Experts

Telemedicine makes it easier for local teams to consult remotely with donor management experts—like intensivists or transplant surgeons—who can offer real-time guidance and support. In pulmonary care, virtual platforms such as video calls, phone, or online systems have improved access to specialists, supported clinical decisions, and reduced the need for patients to travel—especially in rural or underserved areas [52,53]. In lung transplantation, teleconsultations help keep care well-coordinated by enabling close collaboration between transplant centers and referring hospitals, allowing patients to benefit from continuous, multidisciplinary input [54,55].

8.2 Artificial Intelligence (AI) for Predictive Modeling and Decision Support

8.2.1 Predictive Modeling of Lung Viability

AI algorithms can be trained on large datasets of donor characteristics, physiological parameters, and procurement data to predict the likelihood of successful EVLP conversion or post-transplant outcomes [56]. These models can help transplant teams make more informed decisions about which DCD lungs are most suitable for transplantation. Moreover, integration of biomarker data with clinical and physiological parameters through AI further enhances predictive accuracy, enabling automated and individualized organ assessment [57].

8.2.2 AI-Guided Remote Monitoring

AI can be used to analyze real-time data transmitted via telemedicine, identifying subtle patterns or trends that might be missed by human observers. This could allow for earlier detection of lung deterioration and more proactive intervention. However, more data is needed before using that data to implement clinical standards for intervention. For example, in chronic respiratory conditions like COPD, machine learning models have demonstrated high predictive accuracy for impending exacerbations by analyzing parameters such as respiratory rate, heart rate, and oxygen saturation [58]. Similar approaches in both chronic and acute care settings have shown that AI-derived alerts can outperform traditional monitoring systems in predicting respiratory failure and other critical events, offering improved accuracy, earlier warning, and fewer false alarms [59,60].

8.2.3 Support for Protocol Implementation

AI can be used to create standardized methods so every team can have similar implementation or best practices to ensure safety (Figure 4). However, it does not replace the individual decision-making needed during thoracoabdominal normothermic regional perfusion (TA-NRP), where factors such as perfusion duration, temperature, and pressure may influence lung quality and recipient outcomes. Current clinical experience shows that TA-NRP protocols still vary across centers, especially in areas like cannulation techniques and monitoring strategies, highlighting the need for more consistent guidance [61,62]. As the technique continues to evolve in procurement, AI may help support the development and dissemination of protocols, but flexibility is still required to tailor care to each donor’s specific circumstances [61,62].

Click to view original image

Figure 4 A visual summary of how donor vitals and biomarkers are processed by an AI model to predict lung viability and guide clinical decision-making.

9. Conclusion

Optimizing donor management strategies is paramount to maximizing the utilization of DCD lungs. This requires a multi-faceted approach encompassing meticulous hemodynamic and ventilatory management, aggressive bronchoscopic clearance, and judicious use of pharmacological interventions. Emerging technologies, particularly telemedicine and AI-guided decision support hold promise for further improving DCD lung quality and expanding the donor pool. However, continued research is needed to address gaps in evidence, refine existing protocols, standardize use, and address ethical considerations to ensure equitable access to lung transplantation.

Author Contributions

Chawannuch Ruaengsri conceptualized the review, developed the overall framework, conducted literature searches, and mainly contributed to the writing process. Miguel Alvarez-Cortes developed all visual elements, including graphics and tables, while Marc Leon, Manuel Quiroz-Flores, and Masafumi Shibata contributed to the overall framework and assisted in drafting sections of the manuscript. Yasuhiro Shudo provided supervision throughout the manuscript's development.

Competing Interests

The authors have declared that no competing interests exist.

AI-Assisted Technologies Statement

AI tools, specifically Open AI’s ChatGPT, were used solely for basic grammar correction and language refinement in this manuscript. All scientific content, data interpretation, and conclusion were independently developed by the authors. The authors reviewed the AI-assisted text to ensure accuracy and accept full responsibility for the content.

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