Domino liver transplants: after a quarter of a century, are we still wasting too many usable grafts?

Abstract

Presenter: Ola Ahmed MD | Washington University, St. Louis Background: There is increasing attention on strategies to expand the organ donor pool. Domino liver transplantation (DLT) has emerged as a rational approach to help combat these concerns. The procedure, however, is not widely employed and remains restricted to a small number of centers. The purpose of this study was to assess the national profile of DLT in the United States and evaluate current donor and recipient outcomes. Methods: National data from 1988- 2020 was extracted from the United Network for Organ Sharing (UNOS) database. Analyses included all pediatric and adult donors and recipients of DLT during this study period. Patient demographics and indications for transplant were collated. Patient disease severity was classified as status 1, 2 or 3 pre-2002 and MELD scores were used from 2002 when available. Donor and recipient outcomes of interest were graft and patient survival. Results: The first DLT registered on the UNOS database occurred in 1996 (Figure 1a) and, since then, 185 DLTs were performed in 42 transplant units by December 2020. Nineteen centers (45%) performed one case during the study period and only 2 centers (5%) completed more than 20 cases in 25 years. The median donor age was 48 years (range: 7.5 months – 73 years) the majority were adult donors (n = 150). Since 1996, 2092 patients were transplanted for granulomatous liver disease and, of these, only 103 ( 22. Graft loss within 12 months of transplant occurred in 3 donors (2%). One-, 3- and 5-year donor survival was 95%, 88% and 77%, respectively (Figure 1b). Recipient graft rejection occurred in 29 patients (16%) within 12 months of DLT and graft loss occurred in 10 patients (5%). Recipient graft survival was 91%, 79% and 73% at 1-, 3- and 5 years (Figure 1c). Overall 1 -, 3- and 5-year recipient survival was 93%, 83% and 76% (Figure 1d). Conclusion: Nationally, DLT uptake by institutions remained low and static over a 25-year period and a large proportion of potential domino donors with granulomatous or metabolic liver disease may be unconscionably excluded from the donor pool. Domino recipients showed excellent short and long-term outcomes following surgery and patient and graft survival were comparable to standard liver transplantation approaches. It is hoped that these findings may inform future discussions on appropriate DLT donor selection and efforts to expand the allograft pool.