Donation After Circulatory Death Recipients Research Articles

A Global Experience of Donation after Circulatory Death for Pediatric Lung Transplantation.

Donation after circulatory death (DCD) lung transplantation has increased, but there is limited data in children. We sought to characterize the international experience of pediatric DCD lung transplant (LT) in comparison to donation after brain death (DBD) to address extreme donor organ shortages in children needing LT. Using the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry, 1453 children (<18yo) LT recipients from January 2004 to June 2018 were identified: 34 (3%) were DCD and 1419 (97%) were DBD recipients. Post-transplant outcomes were compared between groups. Propensity score method was used to derive matched cohorts and were compared between groups. DCD and DBD recipients were of similar age, with cystic fibrosis being the most frequent indication for LT in both groups (64.5% vs. 57.5%, respectively). Kaplan-Meier analysis demonstrated similar survival between DCD and DBD cohorts, whereas propensity score-matched recipients also identified similar post-transplant survival in both groups (P=0.098). Secondary analysis found that DCD LT recipients had a longer post-transplant length of hospital stay (unmatched cohorts: 36.5d vs. 20d, p=0.022; matched cohort: 26d vs. 19d, p=0.016), and shorter time to acute cellular rejection (ACR) (unmatched cohorts: 248d vs. 560d, p=0.039; matched cohorts: 248d vs. 1650d,p=0.059). Due to DCD being a key contributor to the increasing number of lung transplants being performed worldwide, the results of this analysis support this organ donation approach in children requiring LT, which would increase access to donor organs. The identification of a potential shorter time to ACR needs further exploration as more DCD pediatric LTs are performed.

Outcomes of donation after circulatory death (DCD) and ex-vivo lung perfusion (EVLP) lung transplantation

BackgroundDonation after circulatory death (DCD) and ex-vivo lung perfusion (EVLP) have been adopted to expand the donor pool in lung transplantation, but outcomes data have been conflicting. This study explores mid-term outcomes of DCD lung transplantation in the modern era, with a focus on EVLP and risk factors for graft failure. MethodsThe United Network for Organ Sharing (UNOS) database was queried for adult lung transplants from 1/1/2015 to 3/1/2023. Loss to follow-up, multiorgan and prior lung transplants were excluded. DCD vs DBD (donation after brain death) lung transplants were compared, with subgroup analysis +/- EVLP. Outcomes were survival and postoperative complications. Overall survival was analyzed separately for an early era (2015-2018) and modern era (2019-2023). ResultsThe study included 1103 DCD (221 with EVLP, and 882 without) and 17973 donation after brain death (DBD) lung transplants (524 with EVLP, and 17449 without). Median follow-up was 3 years. DCD donors were less likely to be CDC high risk (19.3% vs 24.1%, p<0.001), have purulence on bronchoscopy (13.3% vs 18.3%, p<0.001) or infiltrates on chest x-ray (66.7% vs 67.8%, p=0.013). EVLP was more likely to be used for DCD transplants (20.0% vs 2.9%, p<0.001).After transplant, DCD recipients were more likely to be reintubated (24.3% vs 18.5%, p<0.001) and require ECMO within 72 hours (14.9% vs 7.8%, p<0.001), and DCD donation was an independent risk factor for these complications on multivariable logistic regression. Overall survival did not differ significantly between DCD and DBD transplants on adjusted survival analysis in the early or modern era (p=0.774 and p=0.468 respectively). On multivariable Cox regression, DCD and EVLP were not independent risk factors for mortality.On subgroup analysis, the DCD+EVLP cohort had significantly worse survival in the modern era, which remained significant after adjusting for donor and recipient factors (p=0.005). EVLP was an independent risk factor for graft failure in the DCD cohort (HR 1.33, 95% CI 1.00-1.77, p=0.047), but did not significantly affect DBD graft survival (p=0.870). Risk factors for graft failure and mortality in the DCD+EVLP cohort included pulmonary hypertension (HR 77.5, 95% CI 6.15-979, p<0.001), transfusion prior to transplant (HR 2.60, 95% CI 1.07-6.31, p=0.035), elevated creatinine (HR 2.82, 95% CI 1.34-5.90, p=0.006), and higher allocation score (HR 1.02, 95% CI 1.00-1.04, p=0.017) ConclusionStudy findings suggest increased risks of mortality and perioperative complications following transplantation with DCD lungs that have undergone EVLP. DCD lung transplantation without EVLP confers equivalent survival but with some increase in perioperative complications. Further investigation and careful recipient selection is warranted to optimize the use of these extended criteria donors in the modern era.

A multicenter analysis of lung transplantation outcomes comparing donation after circulatory death and donation after brain death

BackgroundDonor organ shortage is a barrier to lung transplantation. Donation after circulatory death (DCD) may offer a solution, although it is underutilized. The objective of this study was to compare survival and other postoperative outcomes between DCD and donation after brain death (DBD). MethodsWe performed a multi-center analysis of Multi-Institutional Extracorporeal Life Support (ECLS) Registry data from 11 lung transplant centers in the United States and Europe. Demographics and clinical parameters were compared using Chi-square test and Fisher's exact test. Survival was assessed by Kaplan-Meier curves and compared by log-rank test with propensity score matching. ResultsOf 1585 patients included in the study, 135 (8.5%) received DCD lungs and 1450 (91.5%) received DBD lungs. DCD recipients had higher rates of obstructive lung disease (p=0.042), longer total ischemic time (p<0.0001), and higher rates of primary graft dysfunction (PGD) at t0h (p<0.0001) and t24h (p=0.0005). PGD at t48h and t72h was not significantly different between DCD and DBD recipients. 90-day survival was lower among DCD recipients (91.2%) compared to DBD recipients (97.4%, p=0.038). Survival was higher without ECLS (p=0.014), whereas EVLP (p=0.47) did not affect survival. ConclusionOverall, our data showed excellent 90-day survival for DCD and DBD recipients, although DCD recipients had relatively lower survival. EVLP was not associated with survival, which may guide future strategies to optimize DCD utilization.

Comparative Study of Acute Kidney Injury in Liver Transplantation: Donation after Circulatory Death versus Brain Death.

BACKGROUND Acute kidney injury (AKI) after orthotopic liver transplantation (OLT) contributes to morbidity and mortality. Donation after circulatory death (DCD) has been established to increase the pool of organs. While surgical complications are reported to be comparable in DCD and donation after brain death (DBD) OLT, there is a knowledge gap concerning adverse kidney events in these 2 groups. MATERIAL AND METHODS In this retrospective cohort study, 154 patients received a DBD and 68 received a DCD organ (2016-2020). The primary outcome was a major adverse kidney event within 30 days (MAKE-30). The secondary outcome was dynamics of AKI and kidney replacement therapy (KRT) during the first postoperative week and on postoperative day 30. Incidence and resolution from AKI and KRT and patient survival (PS) 30 days after OLT were compared between the DCD and DBD recipients. RESULTS MAKE-30 incidence after OLT was comparable in DCD (n=27, 40%) vs DBD (n=41, 27%) recipients (risk ratio 1.49 [95% CI 1.01, 2.21], p=0.073). AKI incidence was comparable in DCD (n=58, 94%) vs DBD (n=95, 82%) recipients (risk ratio 1.14 [95% CI: 1.03, 1.27], P=0.057). Overall, 40% (n=88) of patients required KRT, with no difference between DCD (n=27, 40%) vs DBD (n=61, 40%) recipients (risk ratio 1.00 [95% CI 0.71, 1.43], P>0.999). Resolution of AKI by day 30 was lower in DCD (n=29, 50%) than in DBD (n=66, 69%) recipients (risk ratio 0.71 [95% CI: 0.53, 0.95], P=0.032). Survival after 30 days (DCD: n=64, 94% vs DBD: n=146, 95%, risk ratio 0.99 [95% CI 0.93, 1.06], P>0.999) was also comparable. CONCLUSIONS MAKE-30, short-term renal outcome, and survival did not significantly differ between DBD and DCD-OLT. Resolution of AKI by day 30 was lower in DCD than in DBD recipients.

Heart Transplantation After Donation After Circulatory Death: Early United States Experience

BackgroundGiven the renewed interest in heart transplantation after donation after circulatory death (DCD), a contemporary analysis of trends and longer-term survival is warranted. MethodsAdult heart transplant recipients (December 2019-September 2023) were identified in the Organ Procurement and Transplantation Network. Recipients were stratified as donation after brain death (DBD) or DCD. DCD procurements were further classified as direct procurement and perfusion (DCD-DPP) or normothermic regional perfusion (DCD-NRP), based on the declaration of death to cross-clamp interval (≥40 minutes DCD-NRP). The main outcome was posttransplant survival at 1 and 3 years. ResultsOf 11,625 transplantations, 792 (7%) involved DCD allografts (249 DCD-NRP, 543 DCD-DPP). The proportion of transplants involving DCD allografts significantly increased from 2% (December 2019) to 11% (January-September 2023, P < .001). Upon adjusted analysis, 1-year posttransplant survival was similar for DBD vs DCD-DPP (hazard ratio [HR], 1.00; 95% CI, 0.66-1.66) or DCD-NRP (HR, 0.92; 95% CI, 0.49-1.72). This remained true at 3 years for DCD-DPP (HR, 1.07; 95% CI, 0.77-1.48) and DCD-NRP (HR, 1.04; 95% CI, 0.62-1.73). Incidence of postoperative stroke, dialysis, acute graft rejection, and primary graft dysfunction were similar across groups. Across various strata of recipient risk and center volume, survival was equivalent between the DBD and DCD cohorts. ConclusionsRates of DCD heart transplantation continue to rise. Across various recipient risk and center volume categories, DCD and DBD recipients show comparable posttransplant survival up to 3 years. These findings encourage broader use of such donors in attempts to expand the organ pool.

Donor-derived cell-free DNA, gene expression profile, and acute rejection in donation after circulatory death (DCD) heart transplant recipients

BackgroundAcute rejection (AR) is a leading cause of early morbidity and mortality in heart transplant (HTx) recipients. There is limited data in donor after circulatory death (DCD) HTx recipients where ischemia reperfusion injury may contribute to development of AR and may be detected early with non-invasive biomarkers such as donor-derived cell-free DNA (dd-cfDNA) and gene expression profile (GEP). The goal of this study is to compare dd-cfDNA, GEP and rejection outcomes in DCD and donor after brain death (DBD) HTx recipients. MethodsThis single-center, retrospective study included DCD and DBD HTx recipients from January 2020 to September 2022. Patients were excluded from the study if dd-cfDNA and GEP were not available. The CareDx HeartCare platform was used to obtain dd-cfDNA (AlloSure-Heart) and GEP (AlloMap) with the highest values for each patient recorded at 6 and 12 months. The mean values for these non-invasive markers were compared between DCD and DBD groups. Patients were followed for clinical outcomes, including treated AR, coronary allograft vasculopathy (CAV) and death, through September 2023. ResultsA total of 156 HTx patients were included with 50 DCD and 106 DBD recipients. Baseline characteristics were similar between DCD and DBD recipients including mean age (58.5 years vs 56.9 years, p = 0.48), male sex (82% vs 76%, p = 0.56) and Caucasian race (46% vs 43%, p = 0.78). There were no significant differences in mean AlloSure-Heart at 6 and 12 months between DCD and DBD recipients. AlloMap was significantly lower at 6 months (p = 0.04), but not at 12 months between DCD and DBD recipients. With respect to clinical outcomes at 1 year, there were no significant differences in treated AR (22% vs 14%, p = 0.32), ISHLT grade ≥ 2 CAV (0 vs 4%, p = 0.44) or mortality (2% vs 0%, p = 0.69) between DCD and DBD recipients. ConclusionsIn this single center study, there were no significant differences in mean dd-cfDNA and treated AR at 1 year between DCD and DBD HTx recipients. There was a significant increase in mean GEP at 6 months, but not at 12 months in the DBD cohort. Overall, there does not appear to be clinically significant cardiac allograft injury related to DCD as measured by non-invasive markers. Further work is needed to confirm these findings.

Abstract 13887: Longitudinal Trends in Donor and Recipient Risk Profile, and Clinical Outcomes, for Donation After Circulatory Death Heart Transplantation

Background: The US rate of Donation after Circulatory Death (DCD) Heart Transplant (HT) increased threefold from 2020 to 2022. While early analyses of DCD HT have suggested similar outcomes compared to donation after brain death HT, this may be the result of a restrictive DCD donor and recipient selection process, intended to minimize risk in the first US DCD HT cohorts. Hypothesis: We hypothesized that risk profiles for DCD HT donors and recipients have increased over time, as DCD HT has rapidly expanded. We sought to identify longitudinal changes in risk profiles for DCD donors and recipients from 2019-2023, and determine if such changes have impacted post-DCD HT clinical outcomes. Methods: We analyzed the UNOS thoracic organ database from December 2019 to March 2023. DCD HT donor and recipient risk characteristics were evaluated over time for significant trend. One-year recipient survival was compared over time. Results: During the study period, 716 DCD HT were performed. Recipients were mostly male (79%), Caucasian (68%), and had mean age of 54 years. Over time, several donor and recipient characteristics were significantly different (Table, Figure). Donors were older, and had increased BMI, creatinine, and agonal phase to cross-clamp time, although overall lower ischemic time. Recipients were more likely to be status 1 or 2, and had increased BMI, waitlist time, creatinine, and CPRA. Donor and recipient comorbidities and mechanical support use were unchanged. Post-HT survival over time was unchanged. Conclusions: Since the first US DCD HT, several donor and recipient risk-factors have increased. These increased risk profiles have not translated into reduced one-year survival.

Donation after circulatory death significantly reduces waitlist times while not changing post–heart transplant outcomes: A United Network for Organ Sharing Analysis

ObjectiveRecently, several centers in the US have begun performing donation after circulatory death (DCD) heart transplants (HT) in adults. We sought to characterize the recent use of DCD HT, waitlist-time, and outcomes compared to donation after brain death (DBD). MethodsUsing the UNOS database, 10,402 adult (>18yo) HT recipients from January 2019-June 2022 were identified: 425(4%) were DCD and 9,977(96%) were DBD recipients. Post-transplant outcomes in matched and unmatched cohorts, and waitlist-times were compared between groups. ResultsDCD and DBD recipients had similar age [57y for both, p=0.791]. DCD recipients were more likely white (67% vs. 60%,p=0.002), on LVAD (40% vs. 32%,p<0.001) & listed as status 4-6 (60% vs. 24%,p<0.001); however, less likely to require inotropes (22% vs. 40%,p<0.001), & preoperative ECMO (0.9% vs. 6%,p<0.001). DCD donors were younger (29 vs. 32y,p<0.001), had less renal dysfunction (15% vs. 39%,p<0.001), diabetes (1.9% vs. 3.8%,p=0.050) or hypertension (9.9% vs. 16%,p=0.001). In matched & unmatched cohorts, early survival was similar (p=0.22). Adjusted waitlist-time was shorter in DCD group (21d vs. 31d,p<0.001) compared to DBD cohort and 5-fold shorter (DCD-22d vs DBD-115d,p<0.001) for candidates in status 4-6 which was 60% of DCD cohort. ConclusionsThe community is using DCD mostly for those recipients who are expected to have extended wait list times (e.g., Durable LVADs, Status >4). DCD recipients had similar post-transplant early survival, and shorter adjusted waitlist-time compared to DBD group. Given this early success, efforts should be made to expand the donor pool using DCD, especially for traditionally disadvantaged recipients on the waitlist.

Outcomes of Heart Transplant Donation After Circulatory Death

BackgroundHeart transplantation using donation after circulatory death (DCD) allografts is increasingly common, expanding the donor pool and reducing transplant wait times. However, data remain limited on clinical outcomes. ObjectivesWe sought to compare 6-month and 1-year clinical outcomes between recipients of DCD hearts, most of them recovered with the use of normothermic regional perfusion (NRP), and recipients of donation after brain death (DBD) hearts. MethodsWe conducted a single-center retrospective observational study of all adult heart-only transplants from January 2020 to January 2023. Recipient and donor data were abstracted from medical records and the United Network for Organ Sharing registry, respectively. Survival analysis and Cox regression were used to compare the groups. ResultsDuring the study period, 385 adults (median age 57.4 years [IQR: 48.0-63.7 years]) underwent heart-only transplantation, including 122 (32%) from DCD donors, 83% of which were recovered with the use of NRP. DCD donors were younger and had fewer comorbidities than DBD donors. DCD recipients were less often hospitalized before transplantation and less likely to require pretransplantation temporary mechanical circulatory support compared with DBD recipients. There were no significant differences between groups in 1-year survival, incidence of severe primary graft dysfunction, treated rejection during the first year, or likelihood of cardiac allograft vasculopathy at 1 year after transplantation. ConclusionsIn the largest single-center comparison of DCD and DBD heart transplantations to date, outcomes among DCD recipients are noninferior to those of DBD recipients. This study adds to the published data supporting DCD donors as a safe means to expand the heart donor pool.

Acute rejection in donation after circulatory death (DCD) heart transplants

Donation after circulatory death (DCD) heart transplantation has promising early survival, but the effects on rejection remain unclear. The United Network for Organ Sharing database was queried for adult heart transplants from December 1, 2019, to December 31, 2021. Multiorgan transplants and loss to follow-up were excluded. The primary outcome was acute rejection, comparing DCD and donation after brain death (DBD) transplants. A total of 292 DCD and 5,582 DBD transplants met study criteria. Most DCD transplants were transplanted at status 3-4 (61.0%) compared to 58.6% of DBD recipients at status 1-2. DCD recipients were less likely to be hospitalized at transplant (26.7% vs 58.3%, p<0.001) and to require intra-aortic balloon pumping (IABP; 9.6% vs 28.9%, p<0.001), extracorporeal membrane oxygenation (ECMO; 0.3% vs 5.9%, p<0.001) or temporary left ventricular assist device (LVAD; 1.0% vs 2.7%, p<0.001). DCD recipients were more likely to have acute rejection prior to discharge (23.3% vs 18.4%, p=0.044) and to be hospitalized for rejection (23.4% vs 11.4%, p=0.003) at a median follow-up of 15months; the latter remained significant after propensity matching. On multivariable logistic regression, DCD donation was an independent predictor of acute rejection (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.00-2.15, p=0.048) and hospitalization for rejection (OR 2.03, 95% CI 1.06-3.70, p=0.026). On center-specific subgroup analysis, DCD recipients continued to have higher rates of hospitalization for rejection (23.4% vs 13.8%, p=0.043). DCD recipients are more likely to experience acute rejection. Early survival is similar between DCD and DBD recipients, but long-term implications of increased early rejection in DCD recipients require further investigation.

DCD liver transplant in patients with a MELD over 35.

Donation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35. We analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching. In the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of <30yo independently reduced the risk of graft loss by 30% (HR, 95%CI: 0.7 (0.9-0.5), p=0.019). Retransplant status was associated with a doubled risk of adverse event (HR, 95%CI: 2.1 (1.4-3.3), p=0.001). The rejection rates at 1y were similar between DCD- and DBD-LTs, (9.3% (35/375) versus 1,541 (8.7% (1,541/17,677), respectively). In highly selected recipient/donor pair, DCD transplantation is feasible and can achieve comparable survival to DBD transplantation. Biliary complications occurred at the expected rates. In the absence of selection, DCD-LTs outcomes remain worse than those of DBD-LTs.

Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors

ObjectiveTo quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. MethodsThe United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. ResultsA total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score–matched cohorts of DBD and DCD recipients. ConclusionsThe use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.

Reality of DCD donor use in pediatric thoracic transplantation in the United States

In the US, the first pediatric donation after circulatory death (DCD) thoracic transplant was done in 2004; however, ethical controversy led to minimal utilization of these donors. The present study was performed to characterize the current state of pediatric DCD heart and lung transplantation (HTx, LTx). Children (<18year old) who underwent HTx or LTx using DCD donors from June 2004 to June 2022 were identified in the United Network for Organ Sharing registry. A total of 14 DCD recipients were identified: 7 (50%) HTx and 7 (50%) LTx. Donor and recipient demographics are described in Table 1. One and 5-year post-transplant survival were as follows: HTx recipients (64% for each) and LTx recipients (86%, 55%). Although often discussed, the national experience with DCD donors for pediatric HTx and LTx remains limited and not being practiced consistently by any pediatric program. Given the critical organ shortage, DCD use in the field of pediatric thoracic transplantation should be strongly considered.

Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States.

To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.

Metabolic Outcomes After Pancreas Transplant Alone From Donation After Circulatory Death Donors-The UK Transplant Registry Analysis.

Extrapolating data from early DCD (donation after circulatory death) kidney transplantation, pancreas transplants from DCD grafts were feared to have worse metabolic outcomes. Hence, we aimed to address the question of pancreas transplant alone (PTA) from DCD donors-are our concerns justified? A UK transplant registry analysis of 185 PTA performed between 2005 and 2018 was done. All early graft losses (<3months) were excluded to allow focus on the metabolic outcomes (HbA1c, weight gain and incidence of secondary diabetic macrovascular complications). The aim was to compare the metabolic outcomes, rejection rates (including the need for steroids), patient and graft survival between DBD (Donation after brainstem death) and DCD groups. After excluding early graft losses, data from 162 PTA (DBD = 114 and DCD = 48) were analyzed. Body mass index of the donor was less in DCD group (DBD = 23.40 vs. DCD = 22.25, p = 0.006) and the rest of the baseline transplant characteristics were comparable. There were no significant differences in the HbA1c, weight gain, rejection rate, and incidence of secondary diabetic macrovascular complications post-transplant between DBD and DCD recipients. The 1-, 5-, and 10-year patient and graft survival were similar in both the groups. PTA from DCD donors have equivalent metabolic outcomes and survival (patient/graft) as that of DBD donors.

Six-month abdominal transplant recipient outcomes from donation after circulatory death heart donors: A retrospective analysis by procurement technique

Standard US practice for donation after circulatory death (DCD) abdominal organ procurement is superrapid recovery (SRR). A newer approach using thoracoabdominal normothermic regional perfusion (TA-NRP) shows promise for better recipient outcomes for all organs, but there are few reports of abdominal recipient outcomes from TA-NRP donors. We used the United Network for Organ Sharing data to identify all cardiac DCD donors from October 1, 2020, to May 20, 2022, and categorized them by recovery procedure (SRR vs TA-NRP). We then identified all liver, kidney, and pancreas recipients of these donors for whom 6-month outcome data were available and compared patient and graft survival, kidney delayed graft function (DGF), and biliary complications between TA-NRP DCD and SRR DCD organ recipients. Patient and graft survival did not differ significantly between groups for either kidney or liver recipients. Significantly fewer TA-NRP kidney recipients developed DGF (12.7% [15/118] vs 42.0% [84/200], P <.001), and TA-NRP and pumped kidneys had lower odds for DGF on multivariate analysis. No liver recipients in either group had biliary complications or were relisted for transplantation for ischemic cholangiopathy. Although long-term outcomes need to be investigated, our early results show similar outcomes for recipients of TA-NRP DCD abdominal organs versus recipients of SRR DCD abdominal organs. We believe that TA-NRP is an effective approach to expand the use of DCD organs.

Selecting DCD Recipients Using Predictive Indices.

Using the Organ Procurement and Transplantation Network database, we performed univariate and multivariate retrospective analyses on 4228 DCD liver allograft recipients. We identified 8 significant factors and incorporated them into the weighted RSI to predict 3-mo survival following DCD liver transplantation with a C-statistic of 0.6971. The most significant recipient risk factors were recipient serum sodium levels >150 mEq/L at transplant, recipient albumin <2.0 g/dL at transplant, and a history of portal vein thrombosis. Because Model for End-Stage Liver Disease (MELD) score components were included as individual predictors, the DCD RSI predicts survival independently of MELD. Upon comparison with 3 previous recipient risk scores-Balance of Risk, Renal Risk Index, Patient-Survival Outcomes Following Liver Transplantation-the DCD RSI was determined to be superior at selecting optimal candidates pre-DCD transplantation, yielding a C-statistic of 0.6971. After verifying the performance of predictive indices for selection of DCD recipients, the DCD RSI is best used to preselect patients for optimized outcomes after DCD transplantation. This can increase utilization of DCD donors by improving outcomes.

Center expansion of liver transplants using donation after circulatory death organs is associated with reduced overall waitlist mortality.

Waitlist outcomes in liver transplantation (LT) for individual recipients are improved by use of allografts procured through donation after circulatory death (DCD). However, the impact of increased DCD acceptance on overall center outcomes is unknown. Using the United Network for Organ Sharing database, 88 centers performing an average of ≥10 LTs/year between 1/2004 and 12/2019 were compared by percent DCD use quartile and categorized into four phenotypes according to temporal usage trends. Overall center median Model for End-stage Liver Disease at LT (MMaT), waitlist mortality, and waiting time were evaluated. The overall DCD rate was 6.1% (N=4906/80,709), ranging from 0% to 25.5%. Centers in the top DCD use quartile had lower MMaT (24 vs. 26; p<.001) and shorter overall waiting times (median 66 days vs. 90 days; p<.001) compared to bottom quartile centers. MMaT increased less over time at centers with increasing DCD use and was lower than at centers with declining DCD use (27 vs. 32; p=.017). Overall waitlist mortality between 2016 and 2019 was lower at increasing DCD use centers (17.8% vs. 22.5%, p=.034), yet did not affect 1-year mortality (p=.747). The improved waitlist outcomes at centers with expanded DCD use extend beyond DCD recipients alone without negative consequences to overall post-LT center metrics.

Abstract 11945: Improved Outcomes in Severe Primary Graft Dysfunction Following Heart Transplantation With Donation After Circulatory Death Compared to Donation After Brain Death

Introduction: Primary graft dysfunction (PGD), the leading cause of early mortality after heart transplant, is more common following heart donation after circulatory death (DCD) than following donation after brain death (DBD). We conducted a single-center, retrospective cohort study to compare the incidence, severity, and outcomes of patients experiencing PGD after DCD compared to DBD heart transplant. Methods: We reviewed the medical records of all adult heart transplant recipients at our institution between March 2016 and December 2021. Patients undergoing multi-organ transplant were excluded. PGD was diagnosed within 24 hours after transplant according to modified ISHLT criteria and was classified by severity and ventricles involved. Results: A total of 459 qualifying patients underwent heart transplant during the study period, of whom 65 (14%) were DCD recipients and 394 (86%) were DBD recipients. The incidence of PGD in DCD and DBD recipients was 34% and 23%, respectively (p = 0.070). DCD recipients were more likely to experience severe, biventricular PGD than DBD recipients (19% vs. 7.3%, p = 0.004). Among patients with severe PGD, DCD recipients experienced shorter duration of mechanical circulatory support (ECMO, VAD, or balloon pump; mean 6.0 ± 2.5 vs. 12.1 ± 11.3 days, p = 0.039; Figure), shorter post-transplant hospital length of stay (32.4 ± 41.1 vs. 61.9 ± 47.7 days, p = 0.004), and a trend toward improved 60-day survival (100% vs. 80%, p = 0.170) and one-year survival (92% [95% CI: 76%-100%] vs. 69% [53%-84%]). Conclusions: DCD heart transplant recipients were more likely to experience severe, biventricular PGD than DBD recipients. Despite this, short- and medium-term outcomes among patients with severe PGD were improved in DCD compared to DBD recipients. These data suggest different mechanisms of graft dysfunction and recovery following DCD compared to DBD and support the expansion of the heart donor pool with DCD in most potential recipients.

Improved Outcomes in Severe Primary Graft Dysfunction After Heart Transplantation Following Donation After Circulatory Death Compared With Donation After Brain Death

Primary graft dysfunction (PGD), the leading cause of early mortality after heart transplantation, is more common following donation after circulatory death (DCD) than donation after brain death (DBD). We conducted a single-center, retrospective cohort study to compare the incidence, severity and outcomes of patients experiencing PGD after DCD compared to DBD heart transplantation. Medical records were reviewed for all adult heart transplant recipients at our institution between March 2016 and December 2021. PGD was diagnosed within 24 hours after transplant according to modified International Society for Heart and Lung Transplant criteria. A total of 459 patients underwent isolated heart transplantation during the study period, 65 (14%) following DCD and 394 (86%) following DBD. The incidence of moderate or severe PGD in DCD and DBD recipients was 34% and 23%, respectively (P = 0.070). DCD recipients were more likely to experience severe biventricular PGD than DBD recipients (19% vs 7.4%; P = 0.004). Among patients with severe PGD, DCD recipients experienced shorter median (Q1, Q3) duration of post-transplant mechanical circulatory support (6 [4, 7] vs 9 [5, 14] days; P = 0.039), shorter median post-transplant hospital length of stay (17 [15, 29] vs 52 [26, 83] days; P = 0.004), and similar 60-day survival rates (100% [95% CI: 76.8%-100%] vs 80.0% [63.1%-91.6%]; P = 0.17) and overall survival (log-rank; P = 0.078) compared with DBD recipients. DCD heart transplant recipients were more likely to experience severe, biventricular PGD than DBD recipients. Despite this, DCD recipients with severe PGD spent fewer days on mechanical circulatory support and in the hospital than similar DBD patients. These findings suggest that patterns of graft dysfunction and recovery may differ between donor types, and they support the expansion of the heart-donor pool with DCD.