Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation.

Raphaël Meier ,Andrew M Posselt,Yvonne Kelly,Sandy Feng,Garrett R Roll,Hillary J Braun,Peter G Stock,Dieter Adelmann,Tyler Lunow-Luke,Nancy L Ascher,Chris E Freise,Seiji Yamaguchi,Zachary C Dietch,Ryutaro Hirose,Daniel G Maluf,Shareef Syed ,⋅Sang-Mo Kang ,James M Gardner,John P Roberts,Claus U Niemann

doi:10.3389/fsurg.2021.808733

Abstract

Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally.Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems.Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not.Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.

Highlights

Despite an increased risk of recipient morbidity and mortality, donation after circulatory death (DCD) donors are increasingly used for liver transplantation (LT) to address the organ shortage and waitlist mortality [1]
In order to compare the performance of a locally developed score vs. scores developed from a national database, we designed an index based on liver graft survival predictors in our local UCSF cohort (total warm ischemia time (WIT)index), and a more complex universal-comprehensive (UC)DCD score based on predictors from the United Network for Organ Sharing (UNOS) cohort
To ensure that we had an effective score derived from a current UNOS cohort we could use to demonstrate our hypothesis, we developed a UC-DCD score

Summary

Introduction

Despite an increased risk of recipient morbidity and mortality, donation after circulatory death (DCD) donors are increasingly used for liver transplantation (LT) to address the organ shortage and waitlist mortality [1]. The majority of DCD liver utilization occurs at a relatively small number of centers in the United States [2]. This is similar to practice patterns in many countries around the world, including the United Kingdom (UK), where much about DCD liver transplantation has been learned. Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally

Methods

Results

Conclusion