*Purpose: Extended criteria donor lungs (ECDL) are defined as those failing to meet ≥1 standard donor criteria (P/F > 300, age < 55, smoking < 20 pack years, clear CXR, no purulent secretions). Reluctance toward their use remains despite encouraging reports of non-inferior outcomes. We sought to evaluate temporal trends in utilization and outcomes of ECDL.

*Methods: We used SRTR data to identify all deceased donor lungs authorized for transplantation from 2005-2019. We used adjusted multi-level logistic regression to estimate odds of utilization and discard for ECDL in each of three transplantation eras, accounting for donor characteristics and center-level variation. We used adjusted Cox regression to characterize patient mortality and all-cause graft failure (ACGF) within and between each era.

*Results: Of 29,921 lungs recovered, 79.6% were ECDL. In 2005, 4.3% of ECDL were discarded versus 7.7% in 2019 (p<0.01). ECDL were more likely to be discarded (aOR 2005-2009: 2.02, p<0.001; 2010-2014: 1.61, p<0.001 ; 2015-2019: 1.77, p<0.001). Post-transplant mortality and ACGF improved over time. Compared to 2005-2010, ECDL recipients from 2015-2019 had a 28%% lower mortality risk (aHR=0.72, p <0.001). From 2015-2019, there were no differences in mortality or ACGF between recipients of standard criteria and ECD lungs.

*Conclusions: Recipients of ECDLs have experienced rates of mortality and graft loss similar to their standard counterparts and their outcomes have improved over time. ECDLs are more likely to be discarded despite similar outcomes and the fact that the vast majority of recovered lungs fail to meet standard donor criteria. Future work should define a ‘high-risk’ donor lung which more consistently confers greater risk to its recipients as well as strategies to improve recovery.

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