Decision modeling in donation after circulatory death liver transplantation

Abstract

Donation after circulatory death (DCD) liver allografts are increasingly used for transplantation. However, the posttransplantation clinical and quality of life outcomes of DCD recipients are traditionally considered to be inferior compared with donation after brain death (DBD) allograft recipients. Decision making for such marginal organs can be difficult. This study investigated the optimal decision to accept or decline a DCD liver allograft for a patient based on their current health. A Markov decision process model was constructed to predict the 5-year clinical course of patients on the liver transplant waiting list. Clinical outcomes were determined from the UK transplant registry or appropriate literature. Quality-adjusted life years (QALYs) were determined using the condition-specific short form of liver disease quality of life (SF-LDQoL) questionnaire. There were 293/374 (78.3%) eligible patients who completed the SF-LDQoL questionnaire. A total of 73 respondents (24.9%) were before transplant and 220 were after transplant (DBD recipient, 56.3%; DCD recipient, 8.5%; ischemic cholangiopathy patient, 2.4%; retransplant recipient, 7.9%). Predictive modeling indicated that QALYs gained at 5 years were significantly higher in DCD recipients (3.77; 95% confidence interval [CI], 3.44-4.10) compared with those who remained on the waiting list for a DBD transplant with Model for End-Stage Liver Disease (MELD) scores of 15-20 (3.36; 95% CI, 3.28-3.43), or >20 (3.07; 95% CI, 3.00-3.14). There was no significant advantage for individuals with MELD scores <15 (3.55; 95% CI, 3.47-3.63). In conclusion, this model predicts that patients on the UK liver transplant waiting list with MELD scores >15 should receive an offered DCD allograft based on the QALYs gained at 5 years. This analysis only accounts for donor-recipient risk pairings seen in current practice. The optimal decision for patients with MELD scores <15 remains unclear. However, a survival benefit was observed when a DCD organ was accepted. Liver Transplantation 23 594-603 2017 AASLD.

Survival advantage for patients accepting the offer of a circulatory death liver transplant

“…Our findings therefore mirror a recent analysis by Mclean et al, that reported that UK liver recipients with a MELD score >15 have a significant increase in their quality of life from accepting, rather than rejecting, a DCD liver offer 27 . However, the Mclean analysis was performed by using Markov modelling, and the critical difference is that the sequential stratification method adopted in the present study matches a patient who receives a DCD liver with all those who were eligible to receive that liver and who had been registered for the same number of days.…”

The effect of liver transplantation on patient‐centred outcomes: a propensity‐score matched analysis

“…However, it should be noted there is some evidence to suggest that clinical outcomes can be equivalent with appropriate patient selection , and a recent study of long‐term DCD‐recipients has demonstrated no difference in HR‐QoL between these groups . While the finding of a lower HR‐QoL in DCD‐organ recipients has important implications for advising patients being offered these organs, it should be emphasized that this does not negate the benefits of higher quality‐adjusted life years gained from accepting a DCD transplantation .…”

“…These studies have demonstrated that liver transplantation provides an overall benefit to quality of life; however, there remains uncertainty around whether this improvement is across all aspects of health. Furthermore, questions remain over the relationship between HR‐QoL and time from transplantation , re‐transplantation , and the use of donation after circulatory death (DCD) liver allografts .…”

Donation After Circulatory Death Is Associated With Similar Posttransplant Survival in All but the Highest‐Risk Hepatocellular Carcinoma Patients

“…HCC patients receive a higher proportion of DCD donors than other LT patients. ( 10,24,25 ) However, the literature on outcomes for HCC patients receiving DCD donors is limited to studies with a very small sample of patients. Such studies have shown no overall differences in post‐LT outcomes.…”