The UK DCD Risk Score: A new proposal to define futility in donation-after-circulatory-death liver transplantation

Schlegel, Andrea; Kalisvaart, Marit; Scalera, Irene; Laing, Richard W.; Mergental, Hynek; Mirza, Darius F.; Perera, Thamara; Isaac, J.; Dutkowski, Philipp; Muiesan, Paolo

doi:10.1016/j.jhep.2017.10.034

Cited by 206 publications

(325 citation statements)

References 47 publications

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“…Despite the uniform application of the super‐rapid donor cannulation by all retrieval teams in the United Kingdom, such technical improvements throughout recent years could not entirely prevent the occurrence of the most‐feared complications including IC . This became even more evident in high‐risk and futile donor‐recipient combinations with more points in the UK DCD score system . Although not evident as an independent risk factor in our cohort, CIT must play an important role because DCD livers retrieved at the most distant centers from our hospital accumulated a higher DCD score through a prolonged cold ischemia due to travel time.…”

Section: Discussionmentioning

confidence: 71%

“…Importantly, with our DCD cohort, we were able to link the increasing risk, as described by the high‐risk and futile group with outcomes and confirm previous reports. DCD livers with a score above 5 points clearly demonstrated more biliary complications and related graft loss when compared with donor‐recipient combinations with lower risk and up to 5 points . As suggested by many, DCD livers from high‐risk and futile donor‐recipient combinations may benefit from a graft assessment and treatment through NRP or ex situ machine perfusion …”

Section: Discussionmentioning

confidence: 90%

“…In addition to the metabolic status of a particular donor liver at the time of treatment withdrawal, multiple factors contribute to the overall accumulation of graft injury . In contrast to known donor and recipient factors, where thresholds were described, the impact of procurement parameters remains less well defined. Despite the uniform application of the super‐rapid donor cannulation by all retrieval teams in the United Kingdom, such technical improvements throughout recent years could not entirely prevent the occurrence of the most‐feared complications including IC .…”

Section: Discussionmentioning

confidence: 99%

“…Given such a system, the retrieval practice did not impact on outcome, and we were therefore able to identify the overall donor and recipient risk as predictors for biliary complications and graft loss. Known risk factors include donor age and BMI, WIT, CIT, recipient age, and severity of underlying liver disease . Thresholds for single risk factors, however, appear very different and depend on the risk related to outcomes that a center is willing to accept .…”

Section: Discussionmentioning

confidence: 99%

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Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom?

et al. 2019

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Parameters of retrieval surgery are meticulously documented in the United Kingdom, where up to 40% of livers are donation after circulatory death (DCD) donations. This retrospective analysis focuses on outcomes after transplantation of DCD livers, retrieved by different UK centers between 2011 and 2016. Donor and recipient risk factors and the donor retrieval technique were assessed. A total of 236 DCD livers from 9 retrieval centers with a median UK DCD risk score of 5 (low risk) to 7 points (high risk) were compared. The majority used University of Wisconsin solution for aortic flush with a median hepatectomy time of 27‐44 minutes. The overall liver injury rate appeared relatively high (27.1%) with an observed tendency toward more retrieval injuries from centers performing a quicker hepatectomy. Among all included risk factors, the UK DCD risk score remained the best predictor for overall graft loss in the multivariate analysis (P < 0.001). In high‐risk and futile donor‐recipient combinations, the occurrence of liver retrieval injuries had negative impact on graft survival (P = 0.023). Expectedly, more ischemic cholangiopathies (P = 0.003) were found in livers transplanted with a higher cumulative donor‐recipient risk. Although more biliary complications with subsequent graft loss were found in high‐risk donor‐recipient combinations, the impact of the standardized national retrieval practice on outcomes after DCD liver transplantation was minimal.

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Section: Discussionmentioning

confidence: 71%

Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom?

et al. 2019

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“…We believe therefore in the balance of risk concept and have developed a new prediction model, where futile DCD donor and recipient combinations are defined. (5) When the overall risk appears high on the UK-DCD-risk-score, options include the following: selecting a different DCD recipient, graft treatment with machine perfusion, or declining the offer.…”

Section: To the Editormentioning

confidence: 99%

Attitudes and barriers to the use of donation after cardiac death livers: Comparison of a United States transplant center survey to the United Network for Organ Sharing data

2017

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We read with great interest the article wherein Sher et al. assess the nationwide practice in donation after circulatory death (DCD) liver transplantation in the United States. (1) On the basis of center criteria, the reported utilization rate of DCD grafts varies between 2% and 14% across the United States. Interestingly, some centers accept DCD livers for higher Model for End-Stage Liver Disease (MELD) candidates, possibly resulting from the MELD-based allocation system.In contrast to the limited donor risk in the United States, we have no hard cutoffs for donor age and body mass index (BMI) in the United Kingdom. Consequently, we focus on restriction of cold storage (maximum of 6-8 hours) and recipient risk. In Birmingham, on the basis of recipient age, underlying disease, and MELD score, we define suitability for DCD grafts already when listing a candidate. Potential recipients with a foreseen prolonged hepatectomy time (ie, regrafting, known portal vein thrombosis) are deemed unsuitable for DCD livers. Admittedly, this selective policy appears easier in our center-driven allocation. However, in the United Kingdom over the last 10 years, we witnessed a utilization rate of approximately 70% for DCD livers, with satisfactory survival rates. (2) Meanwhile in our center, we are using more marginal DCD grafts while maintaining graft survival rates that are not inferior to donation after brain death grafts. (3) Furthermore, we recently found that DCD livers from elderly donors >60 years achieve excellent outcomes, provided other risk factors are limited. (4) Although no consensus regarding thresholds of specific risk factors exists, boundaries have recently been suggested not only for donor age, but also for donor warm ischemia, cold storage, MELD, and BMI. We believe therefore in the balance of risk concept and have developed a new prediction model, where futile DCD donor and recipient combinations are defined. (5) When the overall risk appears high on the UK-DCD-risk-score, options include the following: selecting a different DCD recipient, graft treatment with machine perfusion, or declining the offer.In summary, this manuscript beautifully shows the current practice in DCD liver transplantation in the United States. On the basis of the UK experience, we would like to transmit our enthusiasm using marginal DCD grafts, and we support the authors' suggestions regarding the restrictions in recipient MELD score and duration of cold storage to further expand the donor pool.

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Deceased Liver Donors

Syed

Feng

2021

Liver Transplantation

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The UK DCD Risk Score: A new proposal to define futility in donation-after-circulatory-death liver transplantation

Cited by 206 publications

References 47 publications

Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom?

Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom?

Attitudes and barriers to the use of donation after cardiac death livers: Comparison of a United States transplant center survey to the United Network for Organ Sharing data

Deceased Liver Donors

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