Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation

Abstract

Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally.Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems.Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not.Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.

Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study

“…In our center, general DCD selection criteria included donor age younger than 60, an estimated CIT lower than 8 h, dWIT<30 min, and a recipient with a MELD score lower than the average. Several DCD scores [11,12,14], including ours [13], have been published to further standardize practices and ensure the best outcomes; however, local constraints (travel distance, local MELD, etc.) and practices can make these scores hard to follow in a global and protocoled manner.…”

“…138 DCD-LTs were compared to 138 DBD-LTs (selected using a propensity score matching technique), and 138 randomly selected LD-LTs. Ischemia times were defined as previously described [13]. Donor and recipient selection and procedures were performed as previously described [13,23,24].…”

“…Ischemia times were defined as previously described [13]. Donor and recipient selection and procedures were performed as previously described [13,23,24]. DCD grafts were procured using the super-rapid technique with local modifications [25].…”

“…However, to date, NMP is not broadly available, and many US centers still avoid DCDs or apply very strict donor selection criteria [9]. In this regard, we and others have developed scores to select donors/recipients in order to optimize outcomes with a special emphasis on minimizing biliary complications [11][12][13][14]. Known risk factors for IC are donor age (>40 years) [6,15], prolonged cold ischemic time (CIT) (>8 h) [6], prolonged dWIT (>20 min), low venous oxygen saturation (SvO 2 ≤ 60) [15], and donor liver extraction time [8,13].…”

“…In this regard, we and others have developed scores to select donors/recipients in order to optimize outcomes with a special emphasis on minimizing biliary complications [11][12][13][14]. Known risk factors for IC are donor age (>40 years) [6,15], prolonged cold ischemic time (CIT) (>8 h) [6], prolonged dWIT (>20 min), low venous oxygen saturation (SvO 2 ≤ 60) [15], and donor liver extraction time [8,13]. Besides IC, other relevant ischemic complications include anastomotic biliary strictures (AS) and bile leaks which were previously shown to range between 10% and 15% in DCD cases, and not be significantly different from DBD rates [6].…”