Differential Impact of Extended-Criteria Donor Use According to Recipient Status in Lung Transplantation: A Nationwide Cohort Study

Background:The use of extended-criteria donors (ECDs) in lung transplantation remains high in Korea; however, their impact on survival outcomes is not fully understood.Methods: We retrospectively analyzed 1,251 adult lung transplant recipients registered with the Korea Network for Organ Sharing (2010-2023).ECDs were defined as donors aged 55 years with a smoking history 20 pack-years or a PaO 2 /FiO 2 ratio 300.Survival outcomes were assessed using Kaplan-Meier analysis and multivariable Cox regression, with subgroup comparisons by urgency (status 0 vs. status 1-4) and age (< 65 vs. 65 years).Results: Of the 1,251 recipients, 33.7% received ECD lungs.In the multivariable analysis, recipient age, urgency status 0, and ECD use were independently associated with increased one-year mortality.In subgroup analyses, ECD use was consistently associated with higher mortality in status 1-4 recipients (P < 0.001), whereas in status 0 recipients it showed only a trend toward decreased survival (P = 0.056).Among elderly recipients, ECD use significantly increased mortality in status 1-4 but showed only a trend toward decreased survival in status 0 (P = 0.071).In contrast, among younger recipients, ECD use increased mortality in status 1-4 but had no significant effect in status 0. Conclusion: ECD use was consistently associated with higher one-year mortality in recipients with urgency status 1-4, irrespective of age.In contrast, among status 0 recipients, the effect differed by age.These findings highlight the importance of incorporating both recipient urgency and age into donor lung selection.