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. 2023 Sep 4:14:1246867.
doi: 10.3389/fimmu.2023.1246867. eCollection 2023.

DCD liver transplant in patients with a MELD over 35

Raphael P H Meier  1   2 , Miguel Nunez  1 , Shareef M Syed  1 , Sandy Feng  1 , Mehdi Tavakol  1 , Chris E Freise  1 , John P Roberts  1 , Nancy L Ascher  1 , Ryutaro Hirose  1 , Garrett R Roll  1
Affiliations

DCD liver transplant in patients with a MELD over 35

Raphael P H Meier et al. Front Immunol. .

Abstract

Introduction: 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.

Methods: 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.

Results: 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).

Discussion: 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.

Keywords: acute rejection; chronic rejection; donation after brain death; donation after circulatory death; high model for end-stage liver disease score; ischemia-reperfusion; liver transplantation; renal failure.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
DCD graft use across UNOS regions with median MELD at transplant (as made available in 2021).
Figure 2
Figure 2
(A) Postoperative labs for DCD-LTs and DBD-LTs. (B) Postoperative creatinine values in DCD-LTs and DBD-LTs with and without renal replacement therapy (RRT) at the time of transplant (txp). p-values: DCD-LTs versus DBD-LTs, * <0.05, *** <0.0001
Figure 3
Figure 3
Kaplan-Meier curves showing unmatched and matched patient’s survival, stratified by type of graft in UCSF (A, B) and UNOS (C, D) cohorts.
See this image and copyright information in PMC

Comment in

References

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