Primary graft dysfunction (PGD) is a clinical syndrome occurring within the first 72 h after lung transplantation and is characterized clinically by progressive hypoxemia and radiographically by patchy alveolar infiltrates. Resulting from ischemia-reperfusion injury, PGD represents a complex interplay between donor and recipient immunologic factors, as well as acute inflammation leading to alveolar cell damage. In the long term, chronic inflammation invoked by PGD can contribute to the development of chronic lung allograft dysfunction, an important cause of late mortality after lung transplant.

Recent work has aimed to identify risk factors for PGD, focusing on donor, recipient and technical factors both inherent and potentially modifiable. Although no PGD-specific therapy currently exists, supportive care remains paramount and early initiation of ECMO can improve outcomes in select patients. Initial success with ex-vivo lung perfusion platforms has been observed with respect to decreasing PGD risk and increasing lung transplant volume; however, the impact on survival is not well delineated.

This review will summarize the pathogenesis and clinical features of PGD, as well as highlight treatment strategies and emerging technologies to mitigate PGD risk in patients undergoing lung transplantation.