AUTHOR=Kubo Yujiro , Giron Juan José , Rodríguez Dávila Guillermo , Alayza Avendaño Felipe , Mongiello Diletta , Cordero Iglesias Pablo , Romero Román Alejandra , Crowley Silvana , Mariscal Andrea , Naranjo Gómez José Manuel , Novoa Valentín Nuria María , Gomez-de-Antonio David 
  
TITLE=Undersized lung grafts in chronic obstructive pulmonary disease transplant recipients: risk factor or acceptable compromise?
  
JOURNAL=Transplant International
  
VOLUME=Volume 39 - 2026
  
YEAR=2026
  
URL=https://www.frontierspartnerships.org/journals/transplant-international/articles/10.3389/ti.2026.16246
  
DOI=10.3389/ti.2026.16246
  
ISSN=1432-2277
  
ABSTRACT=Size matching is an important concern during lung allocation for lung transplantation (LTx). Although some mismatch is accepted—often favoring larger grafts for patients with chronic obstructive pulmonary disease (COPD)—the optimal strategy remains unclear. This study evaluated the impact of graft size mismatch on postoperative outcomes in COPD. We retrospectively reviewed 130 of 491 patients who underwent LTx at a single center between January 2013 and December 2023. Patients were classified into three groups based on donor-to-recipient predicted total lung capacity ratio: undersized (<0.9), size-matched (0.9–1.1), and oversized (≥1.1). Donor and recipient characteristics were collected. Primary graft dysfunction (PGD) was the primary endpoint; overall survival was secondary. Of the 130 patients, 17 (13%) received undersized grafts, 67 (52%) size-matched grafts, and 46 (35%) oversized grafts. The undersized group had a lower incidence of PGD at 48 and 72 h than other groups (p < 0.01 and p = 0.02). Grade 3 PGD at 72 h was less frequent among groups (p = 0.03). Overall survival was higher in the undersized group (p = 0.018 and p = 0.045). Oversized grafts may not be optimal for LTx in COPD. Undersized grafts appear to be a viable strategy.