High-risk Donor Lungs Research Articles

Transplantation of initially rejected donor lungs using ex vivo lung perfusion: A 5-year experience.

Ex vivo lung perfusion (EVLP) is a method for the evaluation and reconditioning of high-risk donor lungs to increase the pool of potential donor lungs. We reviewed all consecutive patients who received lung transplants from May 2012 to May 2017 with follow-up until July 2021. EVLP was used in lungs initially rejected due to inadequate oxygenation but without other contraindications. Lungs with improved oxygenation levels above the threshold were transplanted. The primary endpoint was the time to graft failure, which was defined as the time from surgery to death or re-transplantation, whichever occurred first. The secondary outcome was freedom from chronic lung allograft dysfunction. A total of 157 patients underwent transplantation during the study period. Thirty-nine patients received EVLP-treated donor lungs. Restricted mean graft survival time up to 7 years is 5.14 years for non-EVLP and 4.19 for EVLP, the difference being -0.95 (confidence interval [CI]-1.93 to 0.04, p = .059). The hazard ratio is 1.66 (CI 1.00-2.75, p = .046). Chronic lung allograft dysfunction was the highest contributor to mortality in both groups. There were significant differences in freedom from chronic lung allograft dysfunction at 12 and 24 months of follow-up (p = .005 and p = .030, respectively). Subgroup analyses revealed that the first patients who received EVLP in 2012-2013 had a substantially worse 5-year graft survival than those who received EVLP more recently in 2016-2017 (14.3% vs. 60.0%). For the latter, the 5-year graft survival was observed to be remarkably close to the non-EVLP group (60.8%). Long-term survival was significantly lower, and lung function was poorer among recipients in the EVLP group than in the non-EVLP group. However, the outcome of patients who received EVLP-treated lungs was observed to improve steadily after the first 2 years after EVLP was introduced in Denmark.

THE PRESENT AND FUTURE OF EX-VIVO LUNG PERFUSION

A current limiting factor within the field of lung transplantation is the availability of viable donor lungs to meet the increasing recipient demand. Exvivo lung perfusion (EVLP) is a novel technology which involves the active ventilation of lungs in a physiologic-like environment outside of the body. During EVLP, high risk donor lungs can be assessed, treated and repaired prior to transplantation. Indeed, many transplant centers have now reported comparable outcomes of using these extended criteria lungs to conventional donors through the use of EVLP. Pre-clinical studies and case reports have demonstrated EVLP as an ideal intervention for targeted therapeutics to address donor-related complications such as infection, pulmonary emboli, and aspiration-injury. In addition, increasing evidence has been put forth demonstrating that EVLP usage can extend the total length of pulmonary preservation, which may serve a variety of clinical purposes.

Incidence of Post-Transplant Cytomegalovirus Viremia in Patients Receiving Lungs After Ex Vivo Lung Perfusion

<h3>Purpose</h3> CMV infection following lung transplant (LTx) is associated with increased morbidity and mortality. Inflammation, infection and longer ischemic times are important risk factors for CMV infection. Ex vivo lung perfusion (EVLP) has helped to successfully increase utilization of high-risk donors over the last decade. However, the impact of EVLP on post-transplant CMV infection is unknown. <h3>Methods</h3> Single-center, retrospective analysis of all LTx recipients from 2010 to 2020. The primary endpoint was comparison of CMV viremia in recipients that received EVLP vs. non-EVLP donor lungs. CMV viremia was defined as CMV PCR > 1000 IU/mL within two years post-transplant. Secondary endpoints were time from LTx to CMV viremia, peak CMV PCR and survival. Outcomes were also compared between the different donor (D)-recipient (R) CMV serostatus matching groups. <h3>Results</h3> Included were 862 recipients of non-EVLP lungs and 389 recipients of EVLP lungs. There was no significant difference in the distribution of the CMV serostatus matching groups. 35.8% of patients in the non-EVLP group developed CMV viremia vs. 31.9% in the EVLP group (p=0.18). Median time to CMV viremia was 234 days [IQR, 179-318] in non-EVLP and 249 days [IQR, 186-313] in EVLP group (p=0.5). The mean±SD peak viremia was 4.1±0.8 log₁₀ IU/mL in the non-EVLP group and 4.2±0.8 log₁₀ IU/mL in the EVLP group (p=0.4). There was also no difference in survival of the viremic patients between the groups (log-rank p=0.8). All outcomes were similar when comparing non-EVLP and EVLP patients within each serostatus matching group (Fig.1). <h3>Conclusion</h3> Lung transplant activities have significantly increased with the use of high-risk donor lungs evaluated on EVLP. The practice of utilizing more injured donor organs via EVLP has not affected CMV viremia rates and severity in lung transplant recipients. EVLP could further provide the opportunity to pre-treat donor lungs prior to implantation, perhaps decreasing incidence of post-transplant CMV infection.

Lung transplant with ex vivo lung perfusion, Chilean and Latin American first experience

The number of patients waiting for a lung transplant worldwide greatly exceeds the number of available donors. Ex vivo lung perfusion is a useful tool that allows marginal donor lungs to be evaluated and reconditioned for a successful lung transplantation. To describe the first Chilean and Latin American experience in ex vivo lung perfusion for marginal donor lungs before transplantation. Descriptive analysis of all ex vivo lung perfusion conducted for marginal donor lungs at a private clinic, from April 2019 to October 2020. High risk donor lungs and rejected lungs from other transplantation centers were included. The "Toronto Protocol" was used for ex vivo lung perfusion. Donor lung characteristics and recipient outcomes were studied. During the study period, five ex vivo lung perfusions were performed. All lungs were reconditioned and transplanted. No complications were associated. There were no primary graft dysfunctions and only one chronic allograft dysfunction. There was no mortality during the first year. The median arterial oxygen partial pressure/fractional inspired oxygen ratio increased from 266 mm Hg in the donor lung to 419 after 3 hours of ex vivo lung perfusion (p = 0.043). ex vivo lung perfusion is a safe and useful tool that allows marginal donor lungs to be reconditioned and successfully transplanted.

Transplanting Marginal Organs in the Era of Modern Machine Perfusion and Advanced Organ Monitoring.

Organ transplantation is undergoing profound changes. Contraindications for donation have been revised in order to better meet the organ demand. The use of lower-quality organs and organs with greater preoperative damage, including those from donation after cardiac death (DCD), has become an established routine but increases the risk of graft malfunction. This risk is further aggravated by ischemia and reperfusion injury (IRI) in the process of transplantation. These circumstances demand a preservation technology that ameliorates IRI and allows for assessment of viability and function prior to transplantation. Oxygenated hypothermic and normothermic machine perfusion (MP) have emerged as valid novel modalities for advanced organ preservation and conditioning. Ex vivo prolonged lung preservation has resulted in successful transplantation of high-risk donor lungs. Normothermic MP of hearts and livers has displayed safe (heart) and superior (liver) preservation in randomized controlled trials (RCT). Normothermic kidney preservation for 24 h was recently established. Early clinical outcomes beyond the market entry trials indicate bioenergetics reconditioning, improved preservation of structures subject to IRI, and significant prolongation of the preservation time. The monitoring of perfusion parameters, the biochemical investigation of preservation fluids, and the assessment of tissue viability and bioenergetics function now offer a comprehensive assessment of organ quality and function ex situ. Gene and protein expression profiling, investigation of passenger leukocytes, and advanced imaging may further enhance the understanding of the condition of an organ during MP. In addition, MP offers a platform for organ reconditioning and regeneration and hence catalyzes the clinical realization of tissue engineering. Organ modification may include immunological modification and the generation of chimeric organs. While these ideas are not conceptually new, MP now offers a platform for clinical realization. Defatting of steatotic livers, modulation of inflammation during preservation in lungs, vasodilatation of livers, and hepatitis C elimination have been successfully demonstrated in experimental and clinical trials. Targeted treatment of lesions and surgical treatment or graft modification have been attempted. In this review, we address the current state of MP and advanced organ monitoring and speculate about logical future steps and how this evolution of a novel technology can result in a medial revolution.

Impact of imipenem concentration in lung perfusate and tissue biopsy during clinical ex-vivo lung perfusion of high-risk lung donors.

Normothermic ex-vivo lung perfusion (EVLP) limits organ donor shortage by potentially using high-risk donor lungs. Microbial burden reduction has been demonstrated after EVLP using antibiotic prophylaxis with imipenem. However, no data have been published on the clinical consequences of the potential residual bacterial burden. Imipenem concentration was measured every hour (T0 to T6) in the lung perfusate and at the end of EVLP (Tf) in biopsies. The antimicrobial activity of perfusate at T1 and Tf against E. coli and K. pneumoniae was evaluated. Lungs were distinguished: no bacterial species in recipients and donors (donor-/recipient-); bacterial species isolated from donors and not from recipients (donor+/recipient-); same bacterial species in both recipients and donors (donor+/recipient+). Interleukin 6 (IL-6) and IL-8 concentrations in lung perfusate, clinical pulmonary infection score (CPIS) and primary graft dysfunction (PGD) were evaluated. Imipenem concentration in perfusate decreased over time. T1 and Tf perfusates exhibited bactericidal activity against E. coli and K. pneumoniae. Overall, T1 perfusates yielded higher bactericidal titers (BTs) than Tf. The donor+/recipient+ group (26% of cases) had higher IL-6 and IL-8 in perfusate and higher CPIS. Recipients with the same bacterial species isolated in their donors had higher risk of pulmonary inflammation and early post-transplant pneumonia. Improvements in antimicrobial strategies during EVLP are warranted to minimize the consequences of donor associated respiratory infection.

The Conversional Efficacy of Ex Vivo Lung Perfusion and Clinical Outcomes in Patients Undergoing Transplantation of Donor Lungs by Ex Vivo Lung Perfusion: A Meta-Analysis.

BackgroundEx vivo lung perfusion (EVLP) is a relatively new technique that can be used to assess and repair the donor lungs, increasing the utilization of high-risk lungs. However, its effect on outcomes of lung transplantation patients is uncertainty. This meta-analysis is conducted to assess the impact of EVLP on donor lungs and outcomes of recipients compared with the standard lung transplantation.Material/MethodsWe systematically searched for studies comparatively analyzing the efficacy of EVLP and standard cold storage in lung transplantation. The hazard ratio (HR), relative risk (RR), and weighted mean difference (WMD) were used as the effect size (ES) to evaluate the survival outcomes, categorical variables, and continuous variables respectively.ResultsA total of 20 published articles (including 2574 donors and 2567 recipients) were eligible. The chest x-ray manifestations and PaO2/FiO2 100% were more deficient in the EVLP group than the standard group. EVLP improved the function of high-risk donor lungs with the conversion rate ranging from 34% to 100%. The EVLP group had a lower incidence of primary graft dysfunction 3, but longer intensive care unit stay. Other clinical outcomes between the 2 groups were similar.ConclusionsThe pooled results indicated that EVLP could be used to assess and improve high-risk donor lungs and had non-inferior postoperative outcomes compared with the standard cold storage. EVLP not only increased the utilization of marginal donors, but also could extend preservation time and reduce the total ischemia time of donors.

Evaluation and reconditioning of donor organs for transplantation through ex vivo lung perfusion.

ABSTRACTObjective:To assess the feasibility and impact of ex vivo lung perfusion with hyperoncotic solution (Steen Solution™) in the utilization of these organs in Brazil.Methods:In this prospective study, we subjected five lungs considered to be high risk for transplantation to 4 hours of ex vivo lung perfusion, with evaluation of oxygenation capacity. High-risk donor lungs were defined by specific criteria, including inflammatory infiltrates, pulmonary edema and partial pressure of arterial oxygen less than 300mmHg (inspired oxygen fraction of 100%).Results:During reperfusion, the mean partial pressure of arterial oxygen (inspired oxygen fraction of 100%) of the lungs did not change significantly (p=0.315). In the first hour, the mean partial pressure of arterial oxygen was 302.7mmHg (±127.66mmHg); in the second hour, 214.2mmHg (±94.12mmHg); in the third hour, 214.4mmHg (±99.70mmHg); and in the fourth hour, 217.7mmHg (±73.93mmHg). Plasma levels of lactate and glucose remained stable during perfusion, with no statistical difference between the moments studied (p=0.216).Conclusion: Ex vivo lung perfusion was reproduced in our center and ensured the preservation of lungs during the study period, which was 4 hours. The technique did not provide enough improvement for indicating organs for transplantation; therefore, it did not impact on use of these organs.

Should High Risk Donors Be Restricted to High Volume Lung Transplant Centers?

Purpose Lung transplant center volume has a positive impact on survival in high risk recipients. We aimed to evaluate if there was a survival advantage when high risk donor lungs were transplanted at centers utilizing them more frequently. Methods The United Network of Organ Sharing database was queried for patients (≥ 18 years) undergoing lung transplant between 2007 and 2016. Donors with PO2 Results There were 65 centers included in the final dataset, 32 LVC and 33 HVC. There were 3283 lungs transplanted at LVCs of which 29% (966) were from high risk donors. There were 13812 lungs transplanted at HVCs of which 38% (5251) were from high risk donors. The 1,3 and 5 year survival of low risk donor lungs was 83%, 65% and 49% at LVC and 85%, 68%, and 54% at HCV respectively (p=0.0008)(Figure1). The 1,3 and 5 year survival of high risk donor lungs was 83%, 64% and 47% at LVC and 85%, 66%, and 52% at high volume centers respectively (p=0.007) (Figure 2). Conclusion While, the overall survival of high risk donors at high volume centers is statistically significantly better than low volume centers, the absolute difference is minimal. It is reasonable for low volume centers to continue to use high risk donor lungs.

Rising to the Challenge of Unmet Need: Expanding the Lung Donor Pool

There is a shortage of lungs available to meet the needs of patient who require lung transplantation. Ex vivo lung perfusion (EVLP) has allowed for the assessment and reconditioning of extended criteria and high-risk donor lungs, allowing for an increased volume of lung transplants. Recently, an invested interest in the utilization donation after cardiac death (DCD) donors has surfaced, in which EVLP has played an important role. Clinical studies have shown that EVLP can recondition donor lungs that initially would be unacceptable for transplantation. In a recent study, the intervention of EVLP was also shown to extend the window of total organ preservation time. Preclinical studies have shown promising results for EVLP to serve as a therapeutic platform to modulate inflammation, reduce edema, and treat infections and aspiration injuries. In addition, studies have shown the potential to recondition lungs of donation after cardiac death donors which suffer from additional injury in comparison to donation after brain death donors. EVLP is dynamic platform that can serve to treat and array of issues prior to transplantation. Indeed, the investigation of these therapeutic arsenals will soon allow physicians to expand the donor organ pool and improve transplantation outcomes.

Towards donor lung recovery-gene expression changes during ex vivo lung perfusion of human lungs.

We and others have demonstrated that acellular normothermic ex vivo lung perfusion of high-risk donor lungs can result in posttransplant outcomes equivalent to that of contemporaneous lung transplantation using standard donor lungs. However, the mechanism of this effect remains unclear. Given the restoration of cellular metabolic activity during normothermic perfusion, one possibility is that of lung healing via natural innate recovery mechanisms. We explored this by examining the gene expression changes occurring in human lungs during ex vivo lung perfusion. Human lungs clinically rejected for transplantation were perfused for 12hours of EVLP with biopsies taken at the start, at 1hour, at 3hours, and then every 3hours thereafter to 12hours. Temporal changes were identified in 2585 genes using the Short Time-series Expression Miner and used for pathway analysis. Despite increases in endothelial markers of inflammation, circulating leukocyte cell-specific gene expression fell over 12hours of ex vivo lung perfusion (EVLP), suggesting an interrupted inflammation response secondary to washout of circulating leukocytes. Analysis of these gene changes suggests lung recovery follows specific stages: cellular death, cellular preservation, cellular reorganization, and cellular invasion. EVLP may improve posttransplant lung function by washout of leukocytes and facilitating innate mechanisms of repair.

Ex Vivo Lung Perfusion

Lung transplantation is a lifesaving therapy for patients suffering from end-stage lung diseases. The number of patients waiting for lung transplantation greatly exceeds the number of donors available. Currently, only 20% of lungs donors are used for transplantation. Ex vivo lung perfusion (EVLP) has been developed as a tool to assess and also potentially repair lungs before transplantation. This article will review the rationale for EVLP and the different EVLP methods including the Toronto EVLP method, describe technical details of EVLP, report on the clinical results of EVLP, and describe the use of EVLP as a platform to deliver different therapies. EVLP has been demonstrated to be a safe method of assessing high-risk donor lungs. The long-term survival and graft function of patients that received high-risk donor lungs assessed and treated with EVLP have been shown to be comparable to those receiving conventional donor lungs. Preclinical studies demonstrate that EVLP can serve as a platform for the delivery of specifically targeted therapies to repair injured lungs. EVLP has demonstrated to be a promising tool for the assessment and recovery of injured donor lungs using pharmacologic agents as well as gene and cellular therapies.

Extracorporeal lung perfusion (ex-vivo lung perfusion).

The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of both a shortage of organ donors and a low utilization rate of lungs from those donors. A novel strategy of donor lung management, ex-vivo lung perfusion (EVLP), that keeps the organ at physiological protective conditions has shown great promise to increase lung utilization by re-evaluating, treating, and repairing donor lungs prior to transplantation. Clinical trials using EVLP have shown the method to be well tolerated and it allows for reassessment and improvement in function from high-risk donor lungs from both brain death and cardiac death donors prior to transplantation. When these lungs were transplanted, low rates of primary graft dysfunction were achieved, and the early outcomes were similar to those with conventionally selected and transplanted lungs. Preclinical studies have also shown a great potential of EVLP as a platform for the delivery of novel therapies to repair injured organs ex vivo and thus further increase the donor lung utilization rate. Development of an ex-vivo treatment arsenal ranging in complexity from pharmacologic to gene and cellular therapies will soon allow clinicians to utilize the full potential of the donor organ pool improving outcomes of lung transplantation.

(83) - Towards Donor Lung Recovery - Gene Expression Changes During Ex Vivo Lung Perfusion

Acellular normothermic ex vivo lung perfusion (EVLP) of high-risk donor lungs has resulted in post-transplant clinical outcomes equivalent to current lung transplantation. However, the mechanism of this effect remains unclear. We examined the gene expression changes occurring in human lungs during 12h of EVLP to better explain this phenomenon.

Functional outcomes and quality of life after normothermic ex vivo lung perfusion lung transplantation

Ex vivo lung perfusion (EVLP) is an effective method to assess and improve the function of otherwise unacceptable lungs, alleviating the shortage of donor lungs. The early results with EVLP have been encouraging, but longer-term results, including functional and patient-reported outcomes, are not well characterized. This retrospective single-center study included all lung transplants performed between September 2008 and December 2012. We investigated whether survival or rate of chronic lung allograft dysfunction (CLAD) differed in recipients of EVLP-treated lungs compared with contemporaneous recipients of conventional donor lungs. We also studied functional (highest forced expiratory volume in 1 second predicted, change in 6-minute walk distance, number of acute rejection episodes) and quality of life outcomes. Of 403 lung transplants that were performed, 63 patients (15.6%) received EVLP-treated allografts. Allograft survival for EVLP and conventional donor lung recipients was 79% vs 85%, 71% vs 73%, and 58% vs 57% at 1, 3, and 5 years after transplant, respectively (log-rank p = not significant). Freedom from CLAD was also similar (log-rank p = 0.53). There were no significant differences in functional outcomes such as highest forced expiratory volume in 1 second predicted (76.5% ± 23.8% vs 75.8% ± 22.8%, p = 0.85), change in 6-minute walk distance (194 ± 108 meters vs 183 ± 126 meters, p = 0.57), or the number of acute rejection episodes (1.5 ± 1.4 vs 1.3 ± 1.3, p = 0.36). The EVLP and conventional donor groups both reported a significantly improved quality of life after transplantation, but there was no intergroup difference. EVLP is a safe and effective method of assessing and using high-risk donor lungs before transplantation and leads to acceptable long-term survival, graft function, and improvements of quality of life that are comparable with conventionally selected donor lungs.

Ex vivo lung perfusion.

Lung transplantation (LTx) is an established treatment option for eligible patients with end-stage lung disease. Nevertheless, the imbalance between suitable donor lungs available and the increasing number of patients considered for LTx reflects in considerable waitlist mortality. Among potential alternatives to address this issue, ex vivo lung perfusion (EVLP) has emerged as a modern preservation technique that allows for more accurate lung assessment and also improvement of lung function. Its application in high-risk donor lungs has been successful and resulted in safe expansion of the donor pool. This article will: (I) review the technical details of EVLP; (II) the rationale behind the method; (III) report the worldwide clinical experience with the EVLP, including the Toronto technique and others; (IV) finally, discuss the growing literature on EVLP application for donation after cardiac death (DCD) lungs.

Ex Vivo Lung Perfusion

The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of both a shortage of organ donors and a low utilization rate of lungs from those donors. A novel strategy of donor lung management – Ex vivo Lung Perfusion (EVLP) - that keeps the organ at physiological protective conditions have shown a great promise to increase lung utilization by reevaluating, treating, and repairing donor lungs prior to transplantation. Clinical trials using EVLP has shown the method to be safe and allow for reassessment and improvement in function from high risk donor lungs from both brain death and cardiac death donors prior transplantation. Pre-clinical studies have also shown a great potential of EVLP as a platform for the delivery of novel therapies to repair injured organs ex vivo and thus further improve lung transplantation outcomes. Herein we describe detailed steps for a successful EVLP procedure.

Strategies for safe donor expansion

The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of both a shortage of organ donors and a low utilization rate of lungs from those donors. Two major innovations in recent years include the use of lungs from donations after cardiac death (DCD) and the use of ex-vivo lung perfusion (EVLP) to assess and improve injured donor lungs. DCD lung transplants now account for about 20% of lung transplants in many centres and outcomes after transplantation have been excellent with this source of donation. Clinical experience using EVLP has shown the method to be well tolerated and allow for reassessment and improvement in function from high-risk donor lungs. When these lungs were transplanted, low rates of primary graft dysfunction were achieved and long-term survival was comparable with standard transplantation. Preclinical studies have shown a great potential of EVLP as a platform for the delivery of novel therapies to repair injured donor lungs. A significant increase on the number of available lungs for transplantation is expected in the coming years with the wider use of DCD lungs and with organ-specific ex-vivo treatment strategies.

Ex vivo lung perfusion (EVLP)

The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of both a shortage of organ donors and a low utilization rate of lungs from those donors. A novel strategy of donor lung management—ex vivo lung perfusion (EVLP)—that keeps the organ at physiological protective conditions has shown a great promise to increase lung utilization by re-evaluating, treating, and repairing donor lungs prior to transplantation. A clinical trial using EVLP has shown the method to be safe and to allow for reassessment and improvement in function from high-risk donor lungs from both brain death and cardiac death donors prior transplantation. When these lungs were transplanted, low rates of primary graft dysfunction were achieved, and the early outcomes were similar to those with conventionally selected and transplanted lungs. Pre-clinical studies have also shown a great potential of EVLP as a platform for the delivery of novel therapies to repair injured organs ex vivo, and thus further increase the donor lung utilization rate.

Apoptosis, Not Necrosis, during Ex-Vivo Lung Perfusion Is Correlated with Severe PGD

Purpose We hypothesized that a donor lung which develops more apoptosis during ex-vivo lung perfusion (EVLP) tends to experience severer primary graft dysfunction (PGD) after transplant and that cell death markers in perfusate can be used for prediction of subsequent PGD3. Methods and Materials This is a single-institution retrospective case-control study. A correlation of the outcome of recipients after EVLP and cell death markers in EVLP perfusate was investigated. From 2008 to 2012, 77 high-risk donor lungs were subjected to normothermic acellular EVLP for 4 to 6 hours. Lungs were judged for transplantation based on physiological assessment. The cases (PGD group, N=8) were patients who developed PGD 3 within 72h after lung transplant. The matched controls (Control group, N=8) were selected from patients who had PGD 0, 1 or 2 within 72 h after transplant. Matching factors were recipient age, gender and lung disease. A matched design was used to minimize biases of recipient factors affecting the outcome. Cell death markers including M30, M65 and HMGB-1 were measured with ELISA in perfusate at 1h and the end of EVLP. Results M30 which indicates epithelial apoptosis didn’t show a significant difference between two groups in perfusate at 1h. However, M30 in PGD group was significantly higher compared to Control group at the end of EVLP (p=0.015). M30 at the end of EVLP increased significantly compared to 1 h (p=0.016). M65 which indicates epithelial apoptosis and necrosis didn’t show a significant difference between two groups in both time-points. HMGB-1, which is a mediator of inflammation / immune response and released from dead cells, was significantly higher in PGD group at the end (p=0.035) but not at 1h of EVLP. Using ROC curve, AUC of M30 at the end of EVLP was 0.84 (95%CI: 0.62-1.06, p=0.035) and AUC of HMGB-1 at the end of EVLP was 0.85 (95%CI: 0.64-1.06, p=0.029). Conclusions Epithelial cell apoptosis is related to subsequent PGD3, but necrosis didn’t correlate with PGD severity. M30 and HMGB-1 are predictive perfusate markers for PGD3.