Liver Transplantation Using Donation After Cardiac Death Donors: Long-Term Follow-Up from a Single Center

Abstract

There is a lack of universally accepted clinical parameters to guide the utilization of donation after cardiac death (DCD) donor livers and it is unclear as to which patients would benefit most from these organs. We reviewed our experience in 141 patients who underwent liver transplantation using DCD allografts from 1993 to 2007. Patient outcomes were analyzed in comparison to a matched cohort of 282 patients who received livers from donation after brain death (DBD) donors. Patient survival was similar, but 1-, 5-and 10-year graft survival was significantly lower in DCD (69%, 56%, 44%) versus DBD (82%, 73%, 63%) subjects (p < 0.0001). Primary nonfunction and biliary complications were more common in DCD patients, accounting for 67% of early graft failures. A donor warm ischemia time >20 min, cold ischemia time >8 h and donor age >60 were associated with poorer DCD outcomes. There was a lack of survival benefit in DCD livers utilized in patients with model for end-stage liver disease (MELD) ≤30 or those not on organ-perfusion support, as graft survival was significantly lower compared to DBD patients. However, DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support had similar graft survival, suggesting a potentially greater benefit of DCD livers in critically ill patients.

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“…The incidence of IC was associated with a 53% increase (P = .001) in 1-year posttransplant costs, and retransplant was associated with a 107% increase (P < .001) in 1-year posttransplant costs. These data were consistent with those of De Vera and associates, 16 who examined 141 DCD and 282 DBD transplants and observed that the costs of DCD were 20% higher for the index admission. In addition, van der Hilst and coworkers 73 reported that the cost per life-year for DBD was €88 913 compared with €112 376 for DCD, and this difference was statistically significant.…”

“…11 Pine and associates. 15 However, other reports have yielded inconsistent results; de Vera and coworkers 16 and Skaro and coworkers 17 reported that patient survival was similar for DCD and DBD recipients but that graft survival was significantly lower in DCD than DBD recipients. In addition, relevant to this investigation, several single-institution studies have failed to identify differences in graft and patient survival rates between DCD and DBD livers.…”

“…13,28 However, single-center analyses have provided conflicting findings about complications in DCD recipients. In some studies, the frequencies of PNF, 14,19,28 hepatic artery thrombosis, 14,16,19,28,32 and acute rejection 15,19,32 after DCD liver transplant did not seem significantly higher than those after DBD liver transplant. Taking a study by DeOliveira and associates 33 as an example, primary IC occurred only in 4 recipients (2.5%) from the DCD group (n = 167) and was absent in the DBD group (n = 333).…”

“…6,[12][13][14][16][17][18]25,[28][29][30] Foley and coworkers 13 reported that rates of overall biliary complications (DCD, 47%; DBD, 26%; P < .01) and IC (DCD, 34%; DBD, 1%; P < .01) were significantly higher in the DCD group. Research conducted by Chan and associates 28 indicated no incidence of PNF from DCD allografts.…”

“…To assess the outcomes of patients receiving DCD liver allografts, we analyzed the available previously published literature, including several single-center studies (Table 1) 6,[12][13][14][15][16][17][18][19] and large studies (Table 2) 7,[20][21][22][23][24][25] of national databases, to compare the outcomes of recipients who received DCD versus DBD donor livers and to better understand the risk factors for graft survival, loss, and failure.…”