Grafts from donation after cardiac death (DCD) donors are used to increase the number of organs available for liver transplantation. There is concern that warm ischemia may impair graft function. We compared our DCD recipients with a case-matched group of donation after brain death (DBD) recipients. Between January 2002 and April 2008, 39 DCD grafts were transplanted. These were matched with 39 DBD recipients on the basis of identified variables that had a significant impact on mortality. These were used to individually match DCD and DBD patients with similar predictive mortality. We compared patient/graft survival, primary non-function (PNF), and rates of complications. Of all liver transplants, 6.1% were DCD grafts. PNF occurred twice in the DCD group. The incidence of nonanastomotic biliary strictures (NABS; 20.5% versus 0%, P ϭ 0.005) and hepatic artery stenosis (HAS; 12.8% versus 0%, P ϭ 0.027) in the DCD group was higher. One-year (79.5% versus 97.4%, P ϭ 0.029) and 3-year (63.6% versus 97.4%, P ϭ 0.001) graft survival was lower in the DCD group. Three-year patient survival was also lower (68.2% versus 100%, P Ͻ 0.0001). Our study is the first to use case-matched patients and compare groups with similar predictive mortality. There was a higher incidence of NABS and HAS in the DCD group. NABS were likely a result of warm ischemia. HAS may have been due to ischemia or arterial injury during retrieval. The DCD group had significantly poorer outcomes, but DCD grafts remain a valuable resource. With careful donor/recipient selection, minimization of ischemia, and good postoperative care, acceptable results can be achieved.

The number of patients awaiting liver transplantation keeps steadily rising with no corresponding rise in suitable grafts for transplantation. There also is an increasing trend of patients dying or being taken off waiting lists because of deterioration while waiting for a transplant. Over the preceding years the use of marginal grafts in liver transplantation has been driven by the critical shortage of donor organs and by emerging data that their use has resulted in a favourable outcome. This review revisits the factors defining marginality of a graft, and the issues faced by transplant units in making the decision to use such a graft. It also looks at the innovations in transplantation geared towards increasing the donor pool and the resulting issues of matching marginal grafts to suitable recipients.

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Grade of recommendation b (wording associated with the grade of recommendation) Strong"Must," "should," or "ILTS recommends" Weak Can," "may," or "ILTS suggestsAccording to Guyatt GH et al. 32 a Level was downgraded if there was poor quality, strong bias or inconsistency between studies; level was upgraded if there was a large effect size.bRecommendations were reached by consensus of the panel and included the quality of evidence, presumed patient-important outcomes and costs.

Background. No data exist to evaluate how hepatectomy time (HT), in the context of donation after cardiac death (DCD) procurement, impacts short- and long-term outcomes after liver transplantation (LT). In this study, we analyze the impact of the time from aortic perfusion to end of hepatectomy on outcomes after DCD LT in the United Kingdom. Methods. An analysis of 1112 DCD donor LT across all UK transplant centers between 2001 and 2015 was performed, using data from the UK Transplant Registry. Donors were all Maastricht Category III. Graft survival after transplantation was estimated using Kaplan-Meier method and logistic regression to identify risk factors for primary nonfunction (PNF) and short- and long-term graft survivals after LT. Results. Incidence of PNF was 4% (40) and in multivariate analysis only cold ischemia time (CIT) longer than 8 hours (hazard ratio [HR], 2.186; 95% confidence interval [CI], 1.113–4.294; P = 0.023) and HT > 60 minutes (HR, 3.669; 95% CI, 1.363–9.873; P = 0.01) were correlated with PNF. Overall 90-day, 1-, 3-, and 5-year graft survivals in DCD LT were 91.2%, 86.5%, 80.9%, and 77.7% (compared with a donation after brain death cohort in the same period [n = 7221] 94%, 91%, 86.6%, and 82.6%, respectively [P < 0.001]). In multivariate analysis, the factors associated with graft survival were HT longer than 60 minutes, donor older than 45 years, CIT longer than 8 hours, and recipient previous abdominal surgery. Conclusions. There is a negative impact of prolonged HT on outcomes on DCD LT and although HT is 60 minutes or longer is not a contraindication for utilization, it should be part of a multifactorial assessment with established prognostic donor factors, such as age (>45 y) and CIT (>8 h) for an appropriately selected recipient.