*Purpose: Utilization of liver allografts from donation after cardiac death (DCD) has gradually increased in the United States. We aimed to analyze overall utilization of DCD allografts with respect to demand for liver transplantation (OLT).

*Methods: All primary, liver-only, deceased donor liver transplants reported to UNOS/OPTN from 2003 to 2017 were evaluated (n=75,087). Three time periods were defined as 2003-2007, 2008-2012, and 2013-2017. Primary endpoints were patient and graft survival. Comprehensive uni- and multivariate statistical methods assessed risk factors for outcomes and compared outcomes between DCD and donation after brain death (DBD). To assess the impact of warm ischemic time, a separate analysis was performed for the period when information were available.

*Results: Of 75,087 OLT, 4158 (6%) patients received DCD allografts. DCD liver allograft utilization progressively increased from 4.5% in the initial time period to 6.8% during the most recent time period. At the same time, the number of centers utilizing DCD significantly increased from 68% to 74%. DCD donor ages were significantly younger, with more white aand male throughout the study period. The number of DCD donors with anoxia as cause of death increased significantly over the analyzed time period while head trauma as cause of death decreased in this population.

DCD recipient 1- and 3-year survival improved significantly from 86%/77% during 2003-2007 to 91% /82% from 2013-2017 (p=0.002). Concomitant improvement in graft function throughout the period was noted. Risk analysis for DCD liver allograft failure adjusted for recipient MELD scores identified increased donor age and prolonged cold ischemic time as significant. Transplants in non-white, non-black recipients showed a significantly higher risk for failure. Non-diabetic recipients demonstrated a significantly lower risk of graft failure or death. Comparison of DCD and DBD liver transplants performed between 2012 and 2017 adjusted for donor and recipient risk factors resulted in a significantly increased relative risk of short time failure 1.69 and long time 1.59 (p=0.0001) for DCD transplants.

*Conclusions: OLT outcomes utilizing DCD allografts represent a minority of all liver transplant activity. Initially poor outcomes are improving with increased utilization and the recognition of donor factors (age, cold ischemic time) associated with improved outcomes. Recipient populations are significantly different and further utilization will be dependent upon enhanced, donor-directed research.

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