Selecting DCD Recipients Using Predictive Indices

Abstract

Donation after circulatory death (DCD) allografts might represent one of the largest untapped sources of liver allografts. Our aim was to identify independent recipient risk factors that predict mortality in DCD allograft recipients to preselect optimal candidates for successful transplantation. Furthermore, we compared the application of our newly constructed DCD Recipient Selector Index (RSI) score to previously developed models to determine superiority in predicting recipient survival.

Methods: Using the Organ Procurement and Transplantation Network database, we performed univariate and multivariate retrospective analyses on 4228 DCD liver allograft recipients.

Results: 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.

Conclusions: 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.

Figure 1.

Kaplan-Meier curve of recipient survival by the Donation after Circulatory Death Recipient Selector Index (DCD RSI) score. The y-axis is the percentage recipient survival of total recipients, and the x-axis is the months post–liver transplant. P < 0.001 for each group by log-rank test with reference to acceptable risk DCD RSI score group.

Figure 2.

Calculations of area under the receiver operating characteristic (ROC) curve for 3-mo survival show a Donation After Circulatory Death Recipient Selector Index (DCD RSI) C-statistic value of 0.6971 (CI, 0.6640-0.7305). CI, confidence interval.