The Changing Landscapes in DCD Liver Transplantation

Abstract

Purpose of Review The transplant community continues to look for ways to help address the discordance between donor liver graft availability and patients on the liver transplant waiting list. Donation after circulatory death (DCD) donor livers represents one potential means to help address this discordance. The present review describes the changing landscape of DCD liver transplantation (LT). Recent Findings The number of DCD LTs performed annually within the USA has continued to grow on an annual basis. Importantly, national data has demonstrated that outcomes with DCD LT have been improving. This improvement has been driven by better understanding of how to successfully utilize these organs through better donor and recipient matching and careful evaluation of both hemodynamics during withdrawal of life support and the refinement of the procurement operation. Summary Despite these improvements in outcome, ischemic cholangiopathy (IC) continues to be the Achilles heel of DCD LT. Emerging technologies such as various forms of machine perfusion may allow for reduction of complications and better prognostication of the risk associated with DCD liver grafts.

Microvascular obstructions in portal bile duct capillaries and hepatic sinusoids during normothermic machine perfusion of marginal human livers

“…We also demonstrate occlusion of the portal tract capillaries (Figure 1ii) which supply bile ducts (arrows). This is a key observation as cholangiocytes are known to be extremely sensitive to ischemia, 4 with ischemic‐type biliary lesions (ITBL) referred to as the Achilles’ heel of liver transplantation 5 . It was hoped that NMP would remove this major hurdle; however, the recent large OrganOx trial showed no benefit of liver NMP on rate of biliary strictures or ischemic cholangiopathy; the portal tract vascular occlusions which we demonstrate (Figure 1ii) could be one potential barrier preventing NMP from ameliorating cholangiocyte ischemia.…”

Applicability of the UK DCD risk score in the modern era of liver transplantation: A U.S. update

“…LT volumes after 2012, corresponding with increased understanding of appropriate donor and recipient selection for minimizing DCDassociated complications. 5 Since then, DCD graft and recipient outcomes have markedly improved in both US and international reports of more recent experiences. 19,20 The validity of the UK DCD Risk Score in a contemporary US cohort -in the context of maturing DCD LT practices and improving outcomes -has yet to be demonstrated.…”

“…Recent studies have reported substantial increases in US DCD LT volumes after 2012, corresponding with increased understanding of appropriate donor and recipient selection for minimizing DCD‐associated complications 5 . Since then, DCD graft and recipient outcomes have markedly improved in both US and international reports of more recent experiences 19,20 .…”

Conditional probability of graft survival in liver transplantation using donation after circulatory death grafts – a retrospective study

“…DCD grafts were reported as one of the strongest adverse risk factors in two well‐known liver donor risk indices from the United States (US) and Europe [4,5]. These grafts are still not well utilized compared with DBD livers, accounting for less than 10% of LT in the US [6,7]. This is primarily attributed to the inherent risks associated with these organs, especially in the early post‐transplant period [8].…”