Donation after cardiac death liver transplantation is marred by inferior outcomes including higher rates of biliary complications and IC as well as increased mortality and graft failure. Despite current federal mandates to increase DCD donation, these serious complications translate into poor outcomes for individuals and increased healthcare costs. These risks should be considered in decisions regarding the utilization of these grafts.

Background-Liver transplantation (LT) from Donation after Cardiac Death (DCD) donors is increasingly being used to address organ shortages. Despite encouraging reports, standard survival metrics have overestimated the effectiveness of DCD livers. We examined the mode, kinetics and predictors of organ failure and resource utilization to more fully characterize outcomes after DCD LT.

Background and Aims Organ scarcity has resulted in increased utilization of donation after cardiac death (DCD) donors. Prior analysis of patient survival following DCD liver transplantation has been restricted to single institution cohorts and a limited national experience. We compared the current national experience with DCD and DBD livers to better understand survival after transplantation. Methods We compared 1,113 DCD and 42,254 DBD recipients from the Scientific Registry of Transplant Recipients database between 1996 and 2007. Patient survival was analyzed using Kaplan-Meier methodology and Cox regression. Results DCD recipients experienced worse patient survival compared to DBD recipients (p<0.001). One and three year survival was 82% and 71% for DCD compared to 86% and 77% for DBD recipients. Moreover, DCD recipients required re-transplantation more frequently (DCD 14.7% versus DBD 6.8%, p<0.001), and re-transplantation survival was markedly inferior to survival after primary transplant irrespective of graft type. Amplification of mortality risk was observed when DCD was combined with cold ischemia time > 12hours (HR=1.81), shared organs (HR=1.69), recipient hepatocellular carcinoma (HR=1.80), recipient age >60 years (HR=1.92), and recipient renal insufficiency (HR=1.82). Conclusions DCD recipients experience signficantly worse patient survival after transplantation. This increased risk of mortality is comparable in magnitude to, but often exacerbated by other well-established risk predictors. Utilization decisions should carefully consider DCD graft risks in combination with these other factors.

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Background Given high dialysis mortality rates for patients >60 years old, accepting a kidney with a high kidney donor profile index (KDPI) score could enable earlier and potentially preemptive transplantation (preKT). However, evidence regarding the risks of high KDPI allografts in older patients is limited. Our objective was to determine the relative benefit for older patients of KDPI>85% transplant either preemptively or not compared with remaining on the waitlist. Methods UNOS data from 2003–2012 for adult deceased donor kidney transplant candidates was analyzed to evaluate patient survival in patients >60 years old for preKT and non-preKT KDPI>85% transplants compared to candidates remaining on the waitlist including patients who received KDPI 0–85% transplants according to multivariate Cox regression models. Results In the first year posttransplant for KDPI>85% recipients >60 years old, preKT had a reduced mortality hazard (HR=0.61, 95%CI=0.41–0.90) and non-preKT an increased mortality hazard (HR= 1.15, 95%CI=1.03–1.27) compared with the waitlist including KDPI 0–85% transplant recipients. At 1–2 years and after 2 years, both KDPI >85% groups had significant reductions in mortality (1–2 yrs: preKT HR= 0.38, 95%CI=0.23–0.60 and non-preKT HR= 0.52, 95%CI=0.45–0.61; and 2+ yrs: preKT HR= 0.50, 95%CI=0.38–0.66 and non-preKT HR= 0.64, 95%CI=0.58–0.70, respectively). Conclusions PreKT and non-preKT KDPI>85% transplant was associated with lower mortality hazard after the first year compared with the waitlist including KDPI 0–85% transplants in patients >60 years old. Further consideration should be given to increased utilization of high KDPI grafts in older patients with the goal of avoiding or limiting time on dialysis.

SUMMARYWith improvements in patient and graft survival after liver transplantation, recipient quality of life (QOL) has become an important focus of patient care and clinical outcomes research. To provide a better understanding of the instruments used to assess QOL in the adult liver transplant population, we conducted a systematic review of the MEDLINE database and Cochrane library. Our review identified 128 relevant articles utilizing more than 50 different QOL instruments. Generic health status instruments are the most commonly used, and among them the Medical Outcomes Study Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Beck Depression Inventory (BDI) are the most prevalent. Few studies (16%) included targeted, disease-specific instruments. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Quality of Life questionnaire, the Liver Disease Quality of Life questionnaire, and the Chronic Liver Disease questionnaire are the most frequently employed targeted instruments; however, these instruments have been designed to assess QOL in patients with chronic liver disease rather than patients after liver transplantation. The present review focuses on the psychometric properties of the existing QOL instruments and discusses their individual strengths and limitations in evaluating liver transplantation recipients. The lack of a gold-standard QOL instrument for liver transplant recipients is an impediment to cross-study comparisons. We conclude that the development of a QOL instrument specifically for liver transplant recipients will improve QOL assessment in this population leading to a more nuanced understanding of the factors that influence transplant recipients' well-being.

Higher rates of graft failure and biliary complications translate into markedly increased direct medical care costs for DCD recipients. These important financial implications should be considered in decisions regarding the use of DCD livers.

BACKGROUND Preemptive kidney transplantation (preKT) is associated with higher patient survival, improved quality of life, and lower costs. However, only a minority of patients receives preKT. The aim of this study was to examine changes over the past decade in rates of preKT, focusing on living donor kidney transplantation (LDKT) and specifically recipients who underwent kidney transplantation within one year of initiating dialysis. METHODS Using United Network of Organ Sharing data, we examined retrospectively all kidney transplant candidates (n=369,103) and recipients (n=141,254) from 2003-2012 in the United States focusing on LDKT (n=47,108). Predictors of preKT were examined, and patient and graft survival were compared for preKT, pre-transplant dialysis < 1 year, and pre-transplant dialysis ≥ 1 year recipients. RESULTS PreKT occurred in only 17% of recipients overall and 31% of LDKT recipients. Medicare patients (OR=0.29, 95%CI=0.28-0.31), diabetics (OR=0.75, 95%CI=0.69-0.80), and minorities (Hispanics OR=0.62, 95%CI=0.57-0.68 & African-Americans OR=0.58, 95%CI=0.53-0.63) were less likely to receive preKT. Dialysis < 1 year recipients comprised 30% of non-preemptive LDKT. Dialysis < 1 year recipients had similar patient survival to preKT (5 yr: preKT 94%, dialysis < 1 yr 94%, & dialysis ≥ 1 yr 89%, p<0.01), but decreased death-censored graft survival (5 yr: preKT 93%, dialysis < 1 yr 89%, & dialysis ≥ 1 yr 89%, p<0.01). CONCLUSIONS PreKT remains an unrealized goal for the majority of recipients. Medicare patients, diabetics, and minorities are less likely to receive preKT. Almost one-third of non-preemptive LDKT recipients dialyze < 1 year, highlighting an important target for improvement.