*Purpose: Given the shortage of deceased-donor livers, donation after cardiac death (DCD) provides an opportunity to expand the donor pool. Due to concern over the inferior outcomes of DCD livers, patients and clinicians have to decide whether to accept a DCD offer, or have the patient remain on the waitlist in hopes of a better offer. We compared the discard rates of DCD vs. donation after brain death (DBD) livers, investigated the survival benefit of DCD offer acceptance for liver waitlist candidates, and explored the outcomes of candidates who declined a DCD offer.

*Methods: Using SRTR data 2009-2015, we estimated the relative rate of discard of DCD vs. DBD livers using modified Poisson regression. We identified 1010 candidates who accepted DCD offers (“acceptors”) and 11184 candidates with comparable MELD at the time of the offer (±2 units) who declined the same DCD offers (“decliners”). We compared the survival of acceptors vs. decliners using weighted Cox regression. We characterized the outcomes of DCD offer decliners using competing risk framework. We also estimated the number of additional liver transplants per year if DCD livers were utilized at the same rate as DBD livers.

*Results: At 1-month post-offer, 2.9% of DCD acceptors died compared to 1.4% of decliners (p<0.001) However, DCD acceptors had lower mortality compared to decliners at 6 months (7.1% vs 7.7%, p<0.001), 1 year (9.4 % vs. 13.4%, p<0.001), 3 years (17.6% vs. 27.4%, p<0.001) and 5 years (22.8% vs. 35.6%, p<0.001). After adjustment, DCD acceptors had 34% lower mortality risk compared to DCD decliners (aHR= _0.52 0.66 _0.84) (Figure 1). Among DCD decliners, only 43.0% were transplanted with a DBD liver, 38.4% were removed from the waitlist, 14.2% died, 2.7% were still waiting for an organ, and 1.7% accepted a DCD offer subsequently (Figure 2). However, 29.9% of recovered DCD (N=3743) livers were discarded compared to 8.1% of DBD livers (N=43519) (p<0.001). Risk of discard for recovered DCD livers was 3.4 times greater compared to recovered DBD livers after adjusting for other factors (aRR= _2.98 3.38 _3.84) (Table). If DCD livers were used at the same rate as DBD livers, it would result in an additional 91 deceased-donor liver transplants per year.

*Conclusions: DCD offer acceptance confers substantial survival benefit, but these livers are three times more likely to be discarded. Broader utilization would increase the organ pool and should be encouraged.

« Back to 2020 American Transplant Congress