Background: Multiple studies have demonstrated that outcomes of DCD liver transplantation (LTx) are inferior to DBD LTx. Thus DCD liver transplantation represents only 7% of liver transplants performed annually in the United States. However, it is unclear whether outcomes after DCD LTx are inferior to DBD liver transplants performed using older donor livers. Thus we sought to determine whether DCD LTx outcomes are also inferior to DBD LTx using livers recovered from donors with age > 60 yrs.

Methods: We performed an analysis of the UNOS dataset that included 52,842 primary, solitary, deceased donor liver transplants performed between 2002 and 2014. The outcomes between all DCD (n=2,639) and DBD (n= 50,203) transplants were compared. DCD transplants with donor age < 50 y, and considered optimal DCD donors (n=2,186), were then compared with DBD liver transplants that were subdivided into 2 groups: donor age <60 y (n= 41,293) and donor age >60 y (n=8,910). Graft survival was determined using Kaplan-Meier analyses. Risk models were constructed using Cox regression analysis.

Results: 5-year graft survival was lower for all DCD vs. DBD transplants (61% vs. 70%, p < 0.001). 5-year DCD liver graft survival using optimal donors was similar to DBD donor livers >60 y (63% vs. 61%, p=ns), but inferior to a DBD donor <60 (63% vs. 72%, p<0.001). Multivariate analysis controlling for recipient age, race, ventilator dependence, cold ischemic time, MELD, and donor BMI demonstrated no increase risk of graft loss at 5 years for livers from optimal DCD donors compared to older DBD donors (HR = 0.998, CI 0.904 -1.080, p=ns). In patients with a MELD score ≥ 35 the 5-year graft survival for DCD recipients was similar to a DBD donor >60 yo (57% vs. 55%, p=ns), but inferior to a DBD donor <60 (57% vs. 69%, p<0.001). Multivariate analysis in recipients with MELD ≥ 35 demonstrated similar risk of graft loss at 5 years between optimal DCD and older DBD livers (HR = 1.001, CI 0.757-1.324, p=ns).

Conclusion: Liver allograft survival in DCD LTx is inferior to that seen in DBD LTx. However, liver allograft survival from optimal DCD donors is not inferior to DBD LTx when older DBD donor livers are used. This is also seen in recipients with MELD score ≥ 35. These data would support the increased use of optimal DCD livers similar to the accepted use of older DBD donors.

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