A comprehensive risk assessment of mortality following donation after cardiac death liver transplant – An analysis of the national registry

Abstract

Background and Aims Organ scarcity has resulted in increased utilization of donation after cardiac death (DCD) donors. Prior analysis of patient survival following DCD liver transplantation has been restricted to single institution cohorts and a limited national experience. We compared the current national experience with DCD and DBD livers to better understand survival after transplantation. Methods We compared 1,113 DCD and 42,254 DBD recipients from the Scientific Registry of Transplant Recipients database between 1996 and 2007. Patient survival was analyzed using Kaplan-Meier methodology and Cox regression. Results DCD recipients experienced worse patient survival compared to DBD recipients (p<0.001). One and three year survival was 82% and 71% for DCD compared to 86% and 77% for DBD recipients. Moreover, DCD recipients required re-transplantation more frequently (DCD 14.7% versus DBD 6.8%, p<0.001), and re-transplantation survival was markedly inferior to survival after primary transplant irrespective of graft type. Amplification of mortality risk was observed when DCD was combined with cold ischemia time > 12hours (HR=1.81), shared organs (HR=1.69), recipient hepatocellular carcinoma (HR=1.80), recipient age >60 years (HR=1.92), and recipient renal insufficiency (HR=1.82). Conclusions DCD recipients experience signficantly worse patient survival after transplantation. This increased risk of mortality is comparable in magnitude to, but often exacerbated by other well-established risk predictors. Utilization decisions should carefully consider DCD graft risks in combination with these other factors.

Inferior survival in liver transplant recipients with hepatocellular carcinoma receiving donation after cardiac death liver allografts

“…There was no significant difference in the mean tumor number (P 5 1.00), TTV (P 5 0.44), or proportion with a TTV > 115 cm 3 (P 5 0.45) between HCC patients receiving DCD allografts (group 3) and HCC patients receiving DBD allografts (group 1). There was no significant difference in the mean AFP level before transplantation between HCC patients receiving DCD allografts and HCC patients receiving DBD allografts (P 5 0.61).…”

“…The total tumor volume (TTV) was calculated by the addition of the volumes of each HCC [(4/ 3)pr 3 ], which were based on the maximum radiological radius of each tumor. For some analyses, previously published endpoints-TTV 115 cm 3 and AFP level 400 ng/mL-were used. 17,18 Pretransplant treatments of HCC were recorded if they occurred at any time between listing and transplantation.…”

“…Recent reports have shown that DCD livers are used more frequently than donation after brain death (DBD) organs in patients with HCC (20.2% versus 13%). 3,4 This may reflect the global tendency to transplant extended criteria organs into recipients with lower unadjusted Model for End-Stage Liver Disease (MELD) scores because of the perception that these patients are better equipped to weather the storm of an extended criteria organ; however, this view has been challenged. 5,6 DCD organs suffer from warm ischemic injury (which is not seen in traditional DBD organs) because of hypoperfusion and hypoxia during the agonal period.…”

Increasing the Tolerance of DCD Hearts to Warm Ischemia by Pharmacological Postconditioning

“…The advent of DCD lung donation has resulted in a 28% increase in transplant numbers in Australia with outcomes comparable to those from NDD donors (5). Livers, however, appear more sensitive to the effects of warm ischemia, with increasing rates of ischemic biliary strictures and worse survival following DCD liver transplantation (6,7). Similar concerns regarding the impact of warm ischemia and irreversible ischemic injury have thus far precluded the use of DCD hearts as cardiac allografts.…”

The Use of Donation After Cardiac Death Allografts Does Not Increase Recurrence of Hepatocellular Carcinoma

“…Donation after cardiac death (DCD) liver allografts have been pursued as one option to address the growing discordance between organ supply and demand by increasing the pool of available organs. Previous reports have demonstrated that proportionately DCD livers are used more frequently than donation after brain death (DBD) livers in patients with HCC (20.2% vs. 13%) (4,5). This is likely due to increasing tendency to use extended criteria organs in recipients with lower biological Model for End-Stage Liver Disease (MELD) scores because of the perception that these recipients are better able to tolerate an extended criteria organ (6).…”