*Purpose: Utilization of extended criteria donation after circulatory death (ECD DCD) livers has remained cautious due to potentially worse outcomes because of higher rates of graft non-function and ischemic cholangiopathy. The objective of this study is to demonstrate that ECD DCD livers can be used safely and with good results.

*Methods: Methods – 135 DCD LTs were retrospectively reviewed in the period between 08/2003 – 05/2018. All patients received more than 7 months follow up.

*Results: ECD DCD livers were defined as follow: 1- donor age greater than 50 years or 2- donor BMI greater than 35kg/m or 3-donor warm ischemia greater than 30 minutes or macrosteatosis greater than 30%. Since July 2011 a protocol was implemented to improve DCD liver transplant outcomes. The impact of this protocol on ECD DCD liver transplant outcomes was evaluated. The time period was divided into – before (Era 1) and after (Era 2) implementation of the optimization protocol. Of total of 135 DCD liver transplants, 62 were with ECD DCD livers. 24 ECD DCD liver transplants were performed in Era 1 and 38 in Era 2. Overall outcomes of ECD DCD liver transplants improved in Era 2, with better 1-year graft survival ( 93% vs 75%; P= 0.07) – fig 1a and lower incidence of IC ( 5% vs 17%; P= 0.03). The patient and graft survival rates were comparable with deceased donor liver transplants ( Log Rank, P= 0.8) – fig 1b

*Conclusions: This study demonstrates that the use of ECD DCD livers is safe and similar to comparable DBD liver transplants. It is an important and still underutilized source to address the liver shortage.

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