*Purpose: Donation after cardiac death (DCD) livers represent a possible expansion to the donor pool, but are frequently discarded as they are associated with a higher risk of mortality and graft loss. We hypothesized that there are certain recipient phenotypes that would tolerate a DCD liver well, and are therefore best suited to receive these grafts.

*Methods: Using US national registry data from the SRTR between 2005-2017, we compared 4,177 recipients of DCD livers to 71,974 recipients of non-DCD livers. We identified recipient factors that amplified (or attenuated) the effect of a DCD liver on mortality and graft loss using interaction analysis. Recipients without amplifying factors (i.e. without risk factors that amplified the negative effect of a DCD liver) or with attenuating factors were classified as preferred recipients. We then used Cox regression to compare mortality and graft loss with DCD livers between preferred and non-preferred recipients.

*Results: Preferred recipients of DCD livers were determined to be recipients with a MELD < 35, with hepatitis C as their indication for transplant, and who received a DCD liver with <8 hours of cold ischemia time. 5-year patient survival with DCD vs. non-DCD livers was 77.3% vs. 75.4% for preferred recipients (p=0.1), and 5-year graft survival was 72.0% vs 73.8% (p=0.9). This translated to no increased risk of mortality (hazard ratio [HR]: _0.780.89_1.01, p=0.08) or graft loss (HR: _0.891.01_1.15, p=0.9) when using DCD livers vs. non-DCD livers for preferred recipients. In contrast, 5-year patient survival with DCD vs. non-DCD livers was 73.3% vs. 76.4% for non-preferred recipients (p<0.001), and 5-year graft survival was 67.2% vs 74.1% (p<0.001). This translated to a 17% increased risk of mortality (HR: _1.091.17_1.26, p<0.001) and a 32% increased risk of graft loss (HR: _1.231.32_1.41, p<0.001) when using DCD vs. non-DCD livers for non-preferred recipients.

*Conclusions: Preferred recipients had equivalent patient and graft survival with DCD compared to non-DCD livers. In contrast, non-preferred recipients had a significantly increased risk of mortality and graft loss with DCD livers. The risks of liver transplantation with DCD livers can be minimized by appropriate recipient matching.

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