The jury is out on the utilization of donors after cardiac death for simultaneous liver and kidney transplantation.

Abstract

The organ shortage continues to worsen, and so it is up to the transplant community to investigate all avenues of increasing the supply of transplantable organs. One such potential supply of transplantable organs comes from donation after cardiac death (DCD) (1). The DCD organs have been successfully used in kidney-alone transplantation with the known risk of higher rates of delayed graft function but similar rates of graft and patient survivals when compared to deceased brain dead (DBD) donors (2, 3). For liver transplantation, the outcomes have been questioned. Most publications show worse outcomes with DCD donors when compared to DBD donors (4–6). Particular concerns involve the development, morbidity and cost of the ischemic cholangiopathy (7, 8). Still, not all recipients have the same needs or life expectancy, and so if the risks and benefits are properly considered and explained, DCD liver-alone transplantation still represents an option for selected patients with end-stage liver disease. In the MELD era, we have seen an increase in the number of simultaneous liver and kidney transplantation (SLK) driven, at least in part, by the importance of renal dysfunction in the calculation of the MELD score. However, the use of DCD donors in SLK transplantation has been poorly investigated, with only a single small report previously published (9). Other studies of SLK are inherently limited because they use as a comparison a nonrandomized cohort of liver transplant-alone patients. In this issue of Transplantation, Alhamad et al. (10) ask important questions regarding the outcomes of organs from DCD donors in the setting of SLK. Importantly, this study decreases previous biases by shifting the control group to a nonrandom zedcohort of DBD SLK recipients. The authors analyzed the United Network Organ Sharing database comparing outcomes of DCD SLK (n=98) versus DBD SLK recipients (n=3,026), transplanted between 2002 and 2011. Based on the demographics, we find that DCD SLK is a rare event comprising 3% of the SLK analyzed in this study. The DCD SLKs were more likely to be imported as a regional or national offer, indicating urgency. That said, the authors looked at several available data points that suggest the recipients of DCD SLK were of similar illness, including being in the hospital, on dialysis and on a ventilator. This is a critical point because outcomes are inexorably linked pretransplant health, and if one group is “sicker” then we might expect and even accept inferior outcomes for this group. In fact, recipients of DBD SLK have a higher “liver component” of their MELD score suggesting that the DCD recipients were sicker overall and perhaps more likely to have multi-system organ failure. Differently from the previous report on outcomes of DCD for five SLKs, the authors found that kidney, liver, and patient survival from DCD donors were inferior to DBD donors at 1, 3, and 5 years (9). Moreover, DCD use was a significant risk factor for kidney and liver allograft failure and also for patient mortality. As transplant centers continue to be heavily scrutinized based on their outcomes, studies such as these are important to help frame the conversation around what are the “expected” outcomes with a given donor and recipient combination. Although risk adjustment for these outcomes, based solely on registry analysis, will always have shortcomings, the data from this study can have an important effect on transplant center’s willingness to take an acceptable risk and allow access to transplant for some ill patients under extreme circumstances. The jury, therefore, is out for professionals involved with difficult decisions regarding the use of DCD organs for ill recipients who are in urgent need of an SLK transplantation.