Evolving utilization of donation after circulatory death livers in liver transplantation: The day of DCD has come

Abstract

Compared to donation after brain death (DBD), livers procured for transplantation from donation after circulatory death (DCD) donors experience more ischemia-reperfusion injury and higher rates of ischemic cholangiopathy due to the period of warm ischemic time (WIT) following withdrawal of life support. As a result, utilization of DCD livers for liver transplant (LT) has generally been limited to short WITs and younger aged donor grafts, causing many recovered DCD organs to be discarded without consideration for transplant. This study assesses how DCD liver utilization and outcomes have changed over time, using OPTN data from adult, first-time, deceased donor, whole-organ LTs between January 1995 and December 2019. Results show that increased clinical experience with DCD LT has translated into increased use of livers from DCD donors, shorter ischemic times, shorter lengths of hospitalization after transplant, and lower rates of retransplantation. The data also reveal that over the past decade, the rate of increase in DCD LTs conducted in the United States has outpaced that of DBD. Together, these trends signal an opportunity for the field of liver transplantation to mitigate the organ shortage by capitalizing on DCD liver allografts that are currently not being utilized.

Keywords: ex vivo liver perfusion; graft survival; liver transplant; machine perfusion; retransplantation.

FIGURE 1

Trends of DCD liver donors and LTs over time. (A) All deceased donors over time. (B) All deceased donor LTs over time. (C) Donor age in DCD LTs over time. (D) Deceased donor livers procured but not transplanted (DCD discard) over time

FIGURE 2

Trends in warm and cold ischemic times in LT. (A) Mean warm ischemic time in DCD LTs over time. (WIT was included in the STAR file only after March 1, 2008). (B) Warm ischemic time distribution (minutes) in DCD LTs. (C) Mean cold ischemic time in deceased donor LTs over time. (D) Cold ischemic time distribution (hours) in DCD LTs

FIGURE 3

Trends in DCD LT recipients. (A) Recipient age in DCD LT over time. (B) Mean lab MELD score of deceased donor liver recipients over time. (C) Mean lab MELD range of DCD LT recipients. (D) Most common diagnoses of DCD LT recipients. *Biliary disease: primary biliary cirrhosis, secondary biliary cirrhosis, primary sclerosing cholangitis, biliary atresia, biliary hypoplasia. Liver disease: acute hepatic necrosis, cirrhosis, alcoholic cirrhosis, hepatitis. Metabolic: familial cholestasis, metabolic disorders. Tumor: primary liver malignancy, secondary liver malignancy. Other: Crohn's disease, cystic fibrosis, total parentalnutrition/hyperalimentation, graft vs host disease, trauma

FIGURE 4

Convergence in DCD vs. DBD (A) hospital length of stay after LT, (B) percent of deceased donor LT recipients requiring retransplant (*no recorded DCD LTs in 1998), and (C) percent of deceased donor liver transplant recipients who had biliary complications (BC) leading to graft failure (GF). (Biliary complications data limited in the STAR file prior to 2002)

FIGURE 5

DCD vs. DBD LT outcomes. (A) Kaplan-Meier curve of DCD vs. DBD LT survival, p-value = 0.027. (B) Kaplan-Meier curve of DCD vs. DBD LT graft survival, p-value <0.001. (C) forest plot of the patient survival (PS) and graft survival (GS) in the propensity score matched cohorts

FIGURE 6

Machine perfusion effect on DCD and DBD LT outcomes. (A) Kaplan-Meier curve of machine perfused vs non-machine perfused LT patient survival, p-value = 0.53 and (B) graft survival, p-value <0.001. (C)Comparisons of mean lab MELD, CIT, and WIT between machine perfused and non-machine perfused liver allografts