National time trends in mortality and graft survival following liver transplantation from circulatory death or brainstem death donors

Abstract

Background Despite high waiting list mortality rates, concern still exists on the appropriateness of using livers donated after circulatory death (DCD). We compared mortality and graft loss in recipients of livers donated after circulatory or brainstem death (DBD) across two successive time periods. Methods Observational multinational data from the United Kingdom and Ireland were partitioned into two time periods (2008–2011 and 2012–2016). Cox regression methods were used to estimate hazard ratios (HRs) comparing the impact of periods on post-transplant mortality and graft failure. Results A total of 1176 DCD recipients and 3749 DBD recipients were included. Three-year patient mortality rates decreased markedly from 19.6 per cent in time period 1 to 10.4 per cent in time period 2 (adjusted HR 0.43, 95 per cent c.i. 0.30 to 0.62; P < 0.001) for DCD recipients but only decreased from 12.8 to 11.3 per cent (adjusted HR 0.96, 95 per cent c.i. 0.78 to 1.19; P = 0.732) in DBD recipients (P for interaction = 0.001). No time period-specific improvements in 3-year graft failure were observed for DCD (adjusted HR 0.80, 95% c.i. 0.61 to 1.05; P = 0.116) or DBD recipients (adjusted HR 0.95, 95% c.i. 0.79 to 1.14; P = 0.607). A slight increase in retransplantation rates occurred between time period 1 and 2 in those who received a DCD liver (from 7.3 to 11.8 per cent; P = 0.042), but there was no change in those receiving a DBD liver (from 4.9 to 4.5 per cent; P = 0.365). In time period 2, no difference in mortality rates between those receiving a DCD liver and those receiving a DBD liver was observed (adjusted HR 0.78, 95% c.i. 0.56 to 1.09; P = 0.142). Conclusion Mortality rates more than halved in recipients of a DCD liver over a decade and eventually compared similarly to mortality rates in recipients of a DBD liver. Regions with high waiting list mortality may mitigate this by use of DCD livers.

Outcomes after liver transplantation using deceased after circulatory death donors: A comparison of outcomes in the UK and the US

“…This study and others have shown outcomes following DCD transplantation in the US to be acceptable 2–6,10 ; however, decade‐specific improvements in DCD transplantation in the UK could act as a further benchmark 44 . This is especially pertinent with one UK‐based analysis now indicating no difference in mortality between those using DCD or DBD livers 10,13,45,46 . and another identifying it better to accept a DCD liver on the waiting list as opposed to waiting for a more optimal DBD liver 14 …”

“…1,2,42 Second, we divided the time after transplantation into two time periods: within the first 90 days and between 90 days and 5 years to investigate differences between the UK and the US in the short-term and longterm post-transplant mortality and graft failure. 5,6,10 Ninety days is increasingly being used to capture short-term surgical outcomes after liver transplantation because, in addition to surgical mortality, it reflects the occurrence of acute rejection and primary nonfunction of the donor liver. 5,6,10 However, this approach assumes that the prognostic impact of risk factors on mortality and graft failure is constant within each of these epochs.…”

“…Additional descriptions of these databases and evidence of their completeness, accuracy and reliability have been published elsewhere. 1,5,6,10,14 Patients undergoing LT for super-urgent indications or with acute liver failure, and those who were receiving multi-organ or domino transplantation were excluded, as were those with missing follow-up information (Figure S1).…”

“…In previous research, a higher mean annual transplant centre volume has been shown to be a pivotal determinant in post-transplant outcomes. 1,2,10,[26][27][28] In the UK, the centralization of liver transplantation services means that per centre the UK consistently has a higher volume of liver transplants. 2 Higher transplant volume may facilitate more centre-specific experience in the matching of donors and recipients that is reflected in overall better longer term posttransplantation outcomes.…”

“…Policies and practices developed to address the discrepancy between the number of patients waiting to receive an LT, and the number of suitable donor organs varies by country 5,6 . In the UK, there has historically been a reliance on livers donated after circulatory death donors (DCD) to provide LT to patients before their disease progressed beyond transplantable criteria 5–11 . In the US, a more conservative approach to the use of DCD and marginal deceased after brain death donors (DBD) has been adopted.…”