Donation After Cardiac Death Allografts Research Articles

Liver allograft findings of donation after cardiac death versus brain death in recipients with hepatitis C related cirrhosis: a matched histologic comparison

As the demand for organ transplantation increases, utilization of liver allografts of donation after cardiac death (DCD) is becoming increasingly necessary. Althoughthe clinical outcomes of DCD allografts have been well described, the histologic features are not well characterized. Liver biopsies (n=131) from age-matched DCD (n=60) and donation after brain death (DBD; n=71) recipients with hepatitis C virus were compared. Histologic features were studied in a blinded fashion, subgrouped into time 0, 0-6 months, and >6 months. In time 0 biopsies, more DCD cases had zone 3 (43.8 vs 29%) and bridging necrosis (19 vs 0%), albeit not statistically significant. At 0-6 months, more DCD cases had portal edema (p=0.01). Pericholangitis (30.4% vs 18.8%) and acute cholestasis (21.7% vs 12.5%) were more common in DCD, but not statistically significant. At >6 months, pericholangitis (19% vs 4.5%) persisted in DCD, although not statistically significant. Overall, both groups had similar bile duct injury, portal inflammation, and fibrosis. Postoperative biliary complications were more common in DCD (19% vs 0%). Three-year and 10-year graft survival and patient outcomes were similar in both cohorts. Biliary alterations were more prevalent in the 0-6 month time period DCD biopsies, reflecting increased vulnerability of this group to biliary complications in the early post-orthotopic liver transplant (OLT) period. This finding may suggest poor graft perfusion despite comparable cold ischemia times. However, these features improved and DCD recipients have similar graft and overall survival compared to DBD recipients, indicating that carefully selected DCD liver allografts are a viable option for transplantation.

Marginal allografts in liver transplantation have a limited impact on length of stay.

The study of marginal liver transplant outcomes, including post-transplant length of stay (LOS), is necessary for determining the practicality of their use. 50155 patients who received transplants from 2012 to 2020 were retrospectively analyzed with data from the Scientific Registry of Transplant Recipients database using Kaplan-Meier survival curves and multivariable Cox regression. Six different definitions were used to classify an allograft as being marginal: 90th percentile Donor Risk Index (DRI) allografts, donation after cardiac death (DCD) donors, national share donors, donors over 70, donors with>30% macrovesicular steatosis, or 90th percentile Discard Risk Index donors. 24% (n=12124) of subjects received marginal allografts. Average LOS was 15.6 days among those who received standard allografts. Among those who received marginal allografts, LOS was found to be highest in those who received 90th percentile DRI allografts at 15.6 days, and lowest in those who received DCD allografts at 12.7 days. Apart from fatty livers (95% CI .86-.98), marginal allografts were not associated with a prolonged LOS. We conclude that accounting for experience and recipient matching, transplant centers may be more aggressive in their use of extended criteria donors with limited fear of increasing LOS and its associated costs.

Donor Treatment With a Hypoxia-Inducible Factor-1 Agonist Prevents Donation After Cardiac Death Liver Graft Injury in a Rat Isolated Perfusion Model.

The protective role of hypoxia-inducible factor-1 (HIF-1) against liver ischemia-reperfusion injury has been well proved. However its role in liver donation and preservation from donation after cardiac death (DCD) is still unknown. The objective of this study was to test the hypothesis that pharmaceutical stabilization of HIF-1 in DCD donors would result in a better graft liver condition. Male SD rats (6 animals per group) were randomly given the synthetic prolyl hydroxylase domain inhibitor FG-4592 (Selleck, 6 mg/kg of body weight) or its vehicle (dimethylsulfoxide). Six hours later, cardiac arrest was induced by bilateral pneumothorax. Rat livers were retrieved 30 min after cardiac arrest, and subsequently cold stored in University of Wisconsin solution for 24 h. They were reperfused for 60 min with Krebs-Henseleit bicarbonate buffer in an isolated perfused liver model, after which the perfusate and liver tissues were investigated. Pretreatment with FG-4592 in DCD donors significantly improved graft function with increased bile production and synthesis of adenosine triphosphate, decreased perfusate liver enzyme release, histology injury scores and oxidative stress-induced cell injury and apoptosis after reperfusion with the isolated perfused liver model. The beneficial effects of FG-4592 is attributed in part to the accumulation of HIF-1 and ultimately increased PDK1 production. Pretreatment with FG-4592 in DCD donors resulted in activation of the HIF-1 pathway and subsequently protected liver grafts from warm ischemia and cold-stored injury. These data suggest that the pharmacological HIF-1 induction may provide a clinically applicable therapeutic intervention to prevent injury to DCD allografts.

Outcomes of Liver Transplantation Using Organ Donation After Brain Death (DBD) versus Organ Donation After Cardiac Death (DCD): A Single Center Experience

Introduction: Donation after cardiac death (DCD) liver allografts have been associated with primary nonfunction, ischemic cholangiopathy, hepatic artery stenosis and a higher re-transplantation rate when compared with donation after brain death (DBD) allografts. The number of liver transplantation (LT) with DCD allografts has increased in the recent years. We present our experience with using this extended criteria donor grafts. Primary objective: To compare patient and graft survival between DBD and DCD allografts. Secondary objective: To compare biliary and vascular rates of LT complications between both groups. Methods: We retrospectively reviewed all LTs performed at a major transplant center from January 2012 to April 2017. We included patients who received a combined liver and kidney transplant (n = 29), and excluded patients who received a split LT (n =4). DCD and DBD allografts were compared using Chisquare, Fischer exact test, log-rank tests and Kaplan-Meier plot analysis. Results: A total of 409 patients were analyzed, 100 patients received DCD grafts, and 309 patients received DBD grafts. There was no significant difference in the recipient age, gender, BMI or donor age, gender and BMI of both groups. The DBD recipients had a higher biological (p = 0.001) and match MELD scores, (p = 0.005) while the DCD donors had a higher donor risk index (p < 0.0001). Cholangiopathy in the DCD group was 12.2% and 3.6% in the DBD group, p = 0.001. Although, the rate of non-anastomotic biliary strictures, however, was significantly different between both groups (Table 1), cholangiopathy did not appear to be significant in predicting patient or graft survival in a sub-group analysis. Patient survival in DCD recipients was 92.7% at 1 year, and 80.3% at 4 years versus 96% at 1 year and 88.5% at 4 years in DBD recipients, p = 0.27. Graft survival in DCD recipients was 88% at 1 year, and 76.3% at 4 years versus 94.1% at 1 year and 78.8% at 4 years in DBD recipients, p = 0.34 (Figure 1).Figure: Patient and graft survival Kaplan-Meier curves.Conclusion: With careful selection, LT outcomes of DCD organs are comparable to DBD organs.Figure: Demographics and outcomes by donor relationship.

The Use of Donation After Cardiac Death Allografts Does Not Increase Recurrence of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) recurrence in patients undergoing liver transplantation (LT) with donation after brain death (DBD) and donation after cardiac death (DCD) allografts has not previously been investigated. Rates and patterns of HCC recurrences were investigated in patients undergoing DBD (N = 1633) and DCD (N = 243) LT between 2003 and 2012. LT for HCC was identified in 397 patients (340 DBD and 57 DCD). No difference in tumor number (p = 0.26), tumor volume (p = 0.34) and serum alphafetoprotein (AFP) (p = 0.47) was seen between the groups. HCC recurrence was identified in 41 (12.1%) patients in the DBD group and 7 (12.3%) patients in the DCD group. There was no difference in recurrence-free survival (p = 0.29) or cumulative incidence of HCC recurrence (p = 0.91) between the groups. Liver allograft was the first site of recurrence in 22 (65%) patients in the DBD group and two (37%) patients in the DCD group (p = 0.39). LT for HCC with DBD and DCD allografts demonstrate no difference in the rate of HCC recurrence. Previously published differences in survival demonstrated between recipients with HCC receiving DBD and DCD allografts despite statistical adjustment can likely be explained by practice patterns not captured by variables contained in the SRTR database.

Hospital Resource Use with Donation after Cardiac Death Allografts in Liver Transplantation: A Matched Controlled Analysis from 2007 to 2011

Although donation after cardiac death (DCD) liver allografts have been used to expand the donor pool, concerns exist regarding primary nonfunction and biliary complications. Our aim was to compare resource use and outcomes of DCD allografts with donation after brain death (DBD) liver allografts. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 11,856 patients who underwent deceased donor liver transplantation (LT) from 2007 to 2011. Patients were divided into 2 cohorts based on type of allograft (DCD vs DBD). Matched pair analysis (n = 613 in each group) was used to compare outcomes of the 2 donor types. Donation after cardiac death allografts comprised 5.2% (n = 613) of all LTs in the studied cohort; DCD allograft recipients were healthier and had lower median Model of End-Stage Liver Disease (MELD) score (17 vs 19; p < 0.0001). Post LT, there was no significant difference in length of stay, perioperative mortality, and discharge to home rates. However, DCD allografts were associated with higher direct cost ($110,414 vs $99,543; p < 0.0001) and 30-day readmission rates (46.4% vs 37.1%; p < 0.0001). Matched analysis revealed that DCD allografts were associated with higher direct cost, readmission rates, and inferior graft survival. While confirming the previous reports of inferior graft survival associated with DCD allografts, this is the first national report to show increased financial and resource use associated with DCD compared with DBD allografts in a matched recipient cohort.

Comparison of Short-Term and Long-Term Outcomes After DCD and DBD Donor Liver Transplantation.

Introduction: Liver transplantation (LT) using donation after cardiac death (DCD) allografts has been increased, however the occurrence of primary non-function (PNF) and ischaemic cholangiopathy (IC) has curbed their expansion. Here we compare the outcome of LT with donation after brain death (DBD) and DCD grafts performed in our institution. Study design: Between 2001-2013 we carried out 255 adult controlled DCD LT, which were compared to matched 255 DBD allografts. DCD grafts had a cut-off of maximum 30 min of warm ischaemia and were allocated to recipients with no previous extensive abdominal surgery. Results: There was no difference in gender and recipient's BMI between DBD and DCD transplants, however DBD donors were older and had longer cold ischaemic time. Patients that received DCD grafts presented higher levels of AST (p<0.0005), however, there was no significant difference in Intensive Care Unit or Hospital stay between the 2 groups. PNF was significantly higher in DCD allografts (p<0.0005); nevertheless, there was no statistically significant difference in the incidence of renal replacement therapy, rejection, biliary or vascular complications between the 2 groups. There were no significant differences in PIC occurrence between the 2 groups. Although more patients with hepatocellular carcinoma were allocated (64.06%) to a DCD graft, there was no difference in HCC recurrence. Overall patient and graft survival was higher in the DBD group (p =0.025, p=0.002). When transplants for HCC are excluded, no difference in overall patient and graft survival are observed. Conclusions: The data shows a favourable outcome of liver transplants using DCD allografts. More work is required to explore the impact of DCD status on HCC recurrence. Minimising CIT and optimising donor / recipient matching are crucial in order to achieve good outcome.

Inferior survival in liver transplant recipients with hepatocellular carcinoma receiving donation after cardiac death liver allografts

The impact of ischemia/reperfusion injury in the setting of transplantation for hepatocellular carcinoma (HCC) has not been thoroughly investigated. The present study examined data from the Scientific Registry of Transplant Recipients for all recipients of deceased donor liver transplants performed between January 1, 1995 and October 31, 2011. In a multivariate Cox analysis, significant predictors of patient survival included the following: HCC diagnosis (P < 0.01), donation after cardiac death (DCD) allograft (P < 0.001), hepatitis C virus-positive status (P < 0.01), recipient age (P < 0.01), donor age (P < 0.001), Model for End-Stage Liver Disease score (P < 0.001), recipient race, and an alpha-fetoprotein level > 400 ng/mL at the time of transplantation. In order to test whether the decreased survival seen for HCC recipients of DCD grafts was more than would be expected because of the inferior nature of DCD grafts and the diagnosis of HCC, a DCD allograft/HCC diagnosis interaction term was created to look for potentiation of effect. In a multivariate analysis adjusted for all other covariates, this interaction term was statistically significant (P = 0.049) and confirmed that there was potentiation of inferior survival with the use of DCD allografts in recipients with HCC. In conclusion, patient survival and graft survival were inferior for HCC recipients of DCD allografts versus recipients of donation after brain death allografts. This potentiation of effect of inferior survival remained even after adjustments for the inherent inferiority observed in DCD allografts as well as other known risk factors. It is hypothesized that this difference could reflect an increased rate of recurrence of HCC.

Evaluation of the updated definition of early allograft dysfunction in donation after brain death and donation after cardiac death liver allografts

An updated definition of early allograft dysfunction (EAD) was recently validated in a multicenter study of 300 deceased donor liver transplant recipients. This analysis did not differentiate between donation after brain death (DBD) and donation after cardiac death (DCD) allograft recipients. We reviewed our prospectively entered database for all DBD (n=377) and DCD (n=38) liver transplantations between January 1, 2006 and October 30, 2011. The incidence of EAD as well as its ability to predict graft failure and survival was compared between DBD and DCD groups. EAD was a valid predictor of both graft and patient survival at six months in DBD allograft recipients, but in DCD allograft recipients there was no significant difference in the rate of graft failure in those with EAD (11.5%) compared with those without EAD (16.7%) (P=0.664) or in the rate of death in recipients with EAD (3.8%) compared with those without EAD (8.3%) (P=0.565). The graft failure rate in the first 6 months in those with international normalized ratio ≥1.6 on day 7 who received a DCD allograft was 37.5% compared with 6.7% for those with international normalized ratio <1.6 on day 7 (P=0.022). The recently validated definition of EAD is a valid predictor of patient and graft survival in recipients of DBD allografts. On initial assessment, it does not appear to be a useful predictor of patient and graft survival in recipients of DCD allografts, however a study with a larger sample size of DCD allografts is needed to confirm these findings. The high ALT/AST levels in most recipients of DCD livers as well as the predisposition to biliary complications and early cholestasis make these parameters as poor predictors of graft failure. An alternative definition of EAD that gives greater weight to the INR on day 7 may be more relevant in this population.

Liver transplantation with donation after cardiac death donors: A comprehensive update

BackgroundUse of donation after cardiac death (DCD) donors has been proposed as an effective way to expand the availability of hepatic allografts used in orthotopic liver transplantation (OLT); yet, there remains no consensus in the medical literature as to how to choose optimal recipients and donors based on available information. MethodsWe queried the United Network of Organ Sharing/Organ Procurement and Transplantation Network database for hepatic DCD allografts used in OLT. As of March 31, 2011, 85,148 patients received hepatic allografts from donation-after-brain-death (DBD) donors, and 2351 patients received hepatic allografts from DCD donors. We performed survival analysis using log-rank and Kaplan-Meier tests. We performed univariate and multivariate analyses using the Cox proportional hazards model. All statistics were performed with SPSS 15.0. ResultsPatients receiving hepatic DCD allografts had significantly worse survival compared with patients receiving hepatic DBD allografts. Pediatric patients who received a hepatic DCD allograft had similar survival to those who received a hepatic DBD allograft. The optimal recipient-related characteristics were age <50 y, International Normalized Ratio <2.0, albumin >3.5 gm/dL, and cold ischemia time <8 h; optimal donor-related characteristics included age <50 y and donor warm ischemia time <20 min. ConclusionsBy identifying certain characteristics, the transplant clinician’s decision-making process can be assisted so that similar survival outcomes after OLT can be achieved with the use of hepatic DCD allografts.

Should donation after cardiac death liver grafts be used for retransplantation?

Introduction. Donation after cardiac death (DCD) donors provide an important source of livers that has been used to expand the donor pool. As a consequence of increased numbers of OLT, allograft failure due to early and late complications and disease recurrence are more commonly encountered. The only life saving treatment for patients with liver allograft failure is liver re-transplantation (LR). The use of DCD liver grafts for LR is controversial.Material and methods. Between February 1998 and June 2008, 10 patients underwent LR with DCD allografts. Five (50%) patients had no post operative complications. The 30 day, 1 year, and 3 year patient survival are 80, 60, and 60%, respectively. When DCD grafts are used for sick patients with high MELD scores for LR, the patient and graft survivals are prohibitively low.Conclusion. We do not recommend utilization of DCD liver grafts for LR if a candidate recipient has moderate to high MELD score.

Kidney Donation after Cardiac Death in Korea

Organ donation after cardiac death (DCD) has been suggested due to the shortage of allografts in Korea. We investigated the outcomes of 446 deceased donor kidney transplant recipients in our center between September 1, 1995, and December 31, 2009. Twenty-four (5.4%) of those patients received DCD kidney grafts. The DCD group had a long intensive care unit stay, frequent inotropics use (such as norepinephrine and dopamine), low mean blood pressure and estimated glomerular filtration rate, and high serum creatinine and deceased donor scores compared to the standard criteria donor (SCD) group and the expanded criteria donor (ECD) group. Mean true warm ischemic time of the DCD group was 59.7 minutes based on asystole time. The DCD group had a long hospital stay after transplantation, but there was no statistically significant difference in delayed graft function and primary nonfunction. Serum creatinine levels at 3 months after transplantation in the ECD and DCD group were significantly higher than the SCD group ( P < .001) but lower in the DCD group than in the ECD group at 6 months and 9 months ( P < .001 and P = .004) posttransplantation. There were no statistically significant differences in serum creatinine levels or in the graft survival rates between groups at 12 months ( P = .160 and P = .737). The use of DCD attracted Korean surgeons because DCD allografts are equivalent to a heart-beating donor. Donors who die during the evaluation of brain death should not be abandoned for procurement, and we need to try to harvest allografts after cardiac death (type 4 DCD) to expand donor pools.

Outcomes Following Renal Transplantation After Multiorgan Retrieval Versus Kidney-Only Retrieval in Donation After Cardiac Death Donors

With the increase of donation after cardiac death (DCD) now including procurements for not only kidney but also liver, pancreas, and lung transplantations, we analyze whether multiorgan DCD retrievals have a negative impact on immediate and short-term renal transplant outcomes due to increased length of time of explantation of the kidney from the donor and the associated risks of re-warming. We performed a retrospective study of all DCD donors from 2002 to 2009 at a single unit. Immediate and short-term outcomes between kidney-only versus multiorgan retrieval were compared. Cold ischaemia was significant between the two groups ( P = .04), but all other variables were nonsignificant. The results show that immediate graft function, rates of acute rejection and graft/recipient survival are comparable when DCD allografts are procured from both multiorgan and kidney-only donors. The comparable outcomes from kidney-only and multiorgan donations in this study may be due to by the highly selective use of donors for multiorgan DCD donation. This selectivity may explain the “better” quality of kidney for these cases in which patients were able to tolerate potentially injurious rewarming.

Hepatitis C recurrence is not adversely affected by the use of donation after cardiac death liver allografts

Many factors can worsen a recurrent hepatitis C virus (HCV) infection after liver transplantation (LT). We sought to determine whether the use of donation after cardiac death (DCD) livers affects HCV recurrence. From January 2000 to June 2008, 37 HCV patients underwent LT with DCD allografts. The outcomes and severity of HCV recurrence were analyzed along with those for 74 matched control patients with HCV who received donation after brain death (DBD) livers. The 2 groups had similar donor and recipient characteristics, immunosuppression regimens, rates of acute cellular rejection (ACR), and HCV profiles. DCD patients had a higher incidence of primary nonfunction (19% versus 3%, P = 0.006) and significantly higher peak aspartate aminotransferase levels in comparison with DBD subjects, suggesting a greater degree of ischemia/reperfusion injury. Although the survival rates were not significantly different, DCD recipients had lower 1- and 5-year patient survival rates (83% and 69% versus 84% and 78%, respectively, P = 0.75) and graft survival rates (70% and 61% versus 82% and 74%, respectively, P = 0.24). Three hundred fourteen protocol and clinically indicated liver biopsy procedures were performed within 6 years after transplantation, and mixed modeling analysis showed that fibrosis progression rates were similar for the 2 groups (0.6 fibrosis units/year according to the Ishak modified staging system). The rates of severe HCV recurrence (retransplantation or death due to recurrent hepatitis C and/or the development of stage 4/6 fibrosis or worse within 2 years) were similar [3 DCD patients (8%) versus 11 DBD patients (15%), P = 0.38], and cytomegalovirus infection (hazard ratio = 7.9, P = 0.002, 95% confidence interval = 2.1-28.9) and ACR (hazard ratio = 6.2, P = 0.002, 95% confidence interval = 2.0-19.7) were the only independent risk factors for severe recurrence. In summary, although there was a trend of poorer overall outcomes in DCD patients, the use of DCD livers did not appear to adversely affect HCV recurrence after LT.

A critical analysis of liver allograft utilization from the US deceased donor pool

A critical analysis of liver allograft utilization from the US deceased donor pool

Liver transplantation using controlled donation after cardiac death donors: An analysis of a large single-center experience

The use of donation after cardiac death (DCD) donors may provide a valuable source of organs for liver transplantation. Concerns regarding primary nonfunction (PNF) and intrahepatic biliary stricture (IHBSs) have limited the enthusiasm for their use. A retrospective analysis of 1436 consecutive deceased donor liver transplants performed between December 1998 and October 2006 was conducted. These included 108 DCD liver transplants, which were compared to 1328 transplants performed with organs from donors meeting the criteria for donation after brain death (DBD). The median follow-up was 48 months. The 1-, 3-, and 5-year patient survival and graft survival for DCD donors were 91.5%, 88.1%, and 88.1% and 79.3%, 74.5%, and 71.0%, respectively. The 1-, 3-, and 5-year patient survival and graft survival for DBD donors were 87.3%, 81.1%, and 77.2% and 81.6%, 74.7%, and 69.1%, respectively. Patient survival and graft survival were not significantly different between DCD donors less than 60 years old, DCD donors greater than 60 years old, and DBD donors. Causes of graft loss included IHBSs (n = 9), PNF (n = 4), recurrent hepatitis C virus (n = 4), hepatic artery thrombosis (n = 1), rejection (n = 2), and patient death (n = 13). Contrary to previously published data, excellent long-term patient survival and graft survival can be obtained with DCD allografts, and in our experience, they are equivalent to those obtained from DBD allografts.

Liver Transplantation Using Donation After Cardiac Death Donors: Long-Term Follow-Up from a Single Center

There is a lack of universally accepted clinical parameters to guide the utilization of donation after cardiac death (DCD) donor livers and it is unclear as to which patients would benefit most from these organs. We reviewed our experience in 141 patients who underwent liver transplantation using DCD allografts from 1993 to 2007. Patient outcomes were analyzed in comparison to a matched cohort of 282 patients who received livers from donation after brain death (DBD) donors. Patient survival was similar, but 1-, 5- and 10-year graft survival was significantly lower in DCD (69%, 56%, 44%) versus DBD (82%, 73%, 63%) subjects (p < 0.0001). Primary nonfunction and biliary complications were more common in DCD patients, accounting for 67% of early graft failures. A donor warm ischemia time >20 min, cold ischemia time >8 h and donor age >60 were associated with poorer DCD outcomes. There was a lack of survival benefit in DCD livers utilized in patients with model for end-stage liver disease (MELD) < or =30 or those not on organ-perfusion support, as graft survival was significantly lower compared to DBD patients. However, DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support had similar graft survival, suggesting a potentially greater benefit of DCD livers in critically ill patients.

Long‐term outcomes of donation after cardiac death liver allografts from a single center

Organ shortage continues to be a major challenge in transplantation. Recent experience with controlled non-heart-beating or donation after cardiac death (DCD) are encouraging. However, long-term outcomes of DCD liver allografts are limited. In this study, we present outcomes of 19 DCD liver allografts with follow-up >4.5 years. During 1998-2001, 19 (4.1%) liver transplants (LT) with DCD allografts were performed at our center. Conventional heart-beating donors included 234 standard criteria donors (SCD) and 214 extended criteria donors (ECD). We found that DCD allografts had equivalent rates of primary non-function and biliary complications as compared with SCD and ECD. The overall one-, two-, and five-yr DCD graft and patient survival was 73.7%, 68.4%, and 63.2%, and 89.5%, 89.5%, and 89.5%, respectively. DCD graft survival was similar to graft survival of SCD and ECD in non hepatitis C virus (HCV) recipients (p > 0.370). In contrast, DCD graft survival was significantly reduced in HCV recipients (p = 0.007). In conclusion, DCD liver allografts are durable and have acceptable long-term outcomes. Further research is required to assess the impact of HCV on DCD allograft survival.

Utilization, Outcomes, and Retransplantation of Liver Allografts From Donation After Cardiac Death

Utilization, outcomes, and retransplantation (ReTx) of liver allografts obtained by donation after cardiac death (DCD) are examined to identify mechanisms to optimize donation. DCD for liver transplantation (LTX) has immediate potential to expand the donor pool but application is limited. Retrospective analysis of the Scientific Registry of Transplant Recipients (SRTR) from January 2002 to April 2007 identified 855 DCD and 21,089 donation after brain death (DBD) adult, initial, whole-organ, liver-only LTX. Donor, recipient, and transplant characteristics were compared. Outcome measures were listing for ReTx within 1 year and graft survival determined as death or ReTx. DCD donors were younger (P < 0.001), with fewer African American and non-white race (P < 0.001), and fewer deaths secondary to stroke (P < 0.001). DCD recipients were older (P < 0.001), with lower Model for End-Stage Liver Disease (MELD) scores (P < 0.001), and less likely in intensive care (P = 0.02) or high-urgency status (P < 0.001). DCD allografts were more frequently imported from another allocation region (12% vs. 7%; P < 0.001). Cox regression analysis of time to DCD graft failure demonstrates higher DCD graft failure within the first 180 days (20.5% DCD vs. 11.5% DBD; P < 0.001) with convergence thereafter. DCD listing for ReTx and graft failure progressed continuously over 180 days versus 20 days in DBD. At ReTx, DCD recipients waited longer and received higher risk allografts (P = 0.039) more often from another region. More DCD recipients remain waiting for ReTx with fewer removed for death, clinical deterioration, or improvement. DCD utilization is impeded by early outcomes and a temporally different failure pattern that limits access to ReTx. Allocation policy that recognizes these limitations and increases access to ReTx is necessary for expansion of this donor population.

Ischemic cholangiopathy following liver transplantation from donation after cardiac death donors

The use of donation after cardiac death (DCD) donor hepatic allografts is becoming more widespread; however, there have been published reports of increased graft failure from specific complications associated with this type of allograft. The complication of ischemic cholangiopathy (IC) has been reported to occur more frequently after the use of DCD hepatic allografts. We report the results of 52 liver transplants from DCD donors and the factors that influenced the development of IC. We conducted a retrospective review of all DCD and donation after brain death (DBD) donor liver recipients from September 2003 through December 2006 at a single institution. Survival and complication rates were compared between the 2 groups. The Cox proportional hazards model was then used to identify recipient and donor factors that predict the development of IC in the DCD group. There was no difference in 1-year patient or graft survival rates between the 2 groups. There was no incidence of primary nonfunction from the DCD allografts. Hepatic artery complications and anastomotic bile duct complications were comparable in the 2 groups. There was, however, an increased risk for the development of IC in the DCD group (13.7% versus 1%, P = 0.001). Donor weight >100 kg and total ischemia times > or =9 hours, in donors older than 50 years of age, predicted the development of IC in the DCD group. In conclusion, there is a higher incidence of IC in recipients receiving DCD donor livers; however, patient and graft outcomes with DCD donors remain comparable to those with DBD donors. Careful donor selection may improve utilization of these grafts.