FILONEX—A Prospective, Randomized Controlled Pilot Safety Study Evaluating the Addition of Hemodiafiltration to EVLP in Marginal Donor Lungs

This randomized controlled pilot trial evaluated the feasibility and safety of integrating hemodiafiltration (HDF) into a six-hour ex vivo lung perfusion (EVLP) circuit to ameliorate metabolic derangements in marginal donor lungs. Thirty marginal lungs were randomized in a 1:1 ratio to standard EVLP or EVLP augmented with HDF. The authors found that HDF strictly maintained physiological perfusate homeostasis (pH, lactate, and electrolytes), whereas the controls exhibited progressive metabolic deterioration. The treatment cohort yielded an 80 percent transplant acceptance rate vs 47 percent in controls, with equivalent excellent short-term post-transplant survival and no severe primary graft dysfunction at 72 hours. The authors thus highlight that preserving physiological pH via HDF limits ischemia-reperfusion injury and endothelial dysfunction, despite unaltered cytokine clearance. In conclusion, while understanding the limitations of a pilot trial with a relatively small sample size, HDF-augmented EVLP is safe, highly feasible, and successfully preserves metabolic homeostasis without compromising clinical outcomes.