Liver transplantation with donation after cardiac death donors as a strategy for recipients with model for end‐stage liver disease score >15: Has the die been cast?
Year: 2017
Type: article
Abstract: See Article on Page 594 Potential conflict of interest: Nothing to report. Despite a record number of adult liver transplantations (LTs) performed in the United States during 2015 (>7000),1 the organ shortage continues and is projected to worsen,2 with greater than one‐third of the most recent cohort of wait‐listed patients suffering death or delisting at 3 years.1 Despite harvesting increasing number of grafts by donation after cardiac death (DCD) and significant improvements in overall graft survival over the last decade,3 the utilization of liver allografts from all available donors has decreased significantly since 2004, with DCD organs conferring the highest adjusted odds ratio (21.3) for nonuse.4 In fact, of 2844 DCD LTs performed in the United States from January 2002 to March 2015, 42 out of a total of 151 LT programs (28%) did not use DCD liver allografts, whereas 10 (6.6%), 20 (13.2%), and 30 (19.8%) of the 151 LT programs performed 41%, 60.2%, and 72.7% of all DCD transplants, respectively.5 This discrepancy undoubtedly reflects hesitation to use DCD organs because of increased biliary complications and ischemic cholangiopathy, with inferior graft and patient survival outcomes.6 However, more recent studies suggest excellent longterm outcomes and quality of life in DCD recipients by optimization of recipient and donor selection.7 In the current issue, McLean et al. describe a Markov model to assist in the decision to accept or decline a DCD allograft stratified by the recipient's Model for End‐Stage Liver Disease (MELD) score.9 The model predicted the 5‐year clinical course for patients on the UK transplant waiting list and found that the predicted quality‐adjusted life years gained at 5 years were significantly higher in recipients accepting a DCD graft compared with patients remaining on the waiting list for a donation after brain death (DBD) donor across all MELD score categories >15. Furthermore, acceptance of a DCD graft conferred the lowest risk of death (12.3%) and highest likelihood of being transplanted and complication‐free (81.3%) at 5 years. A recent analysis demonstrated that 84% of all patients who died or were removed from the United Network for Organ Sharing waiting list had received 1 or more prior liver offers, 68% of which were refused for donor quality.10 Thus, acceptance of a DCD organ, traditionally considered to be an inferior or marginal graft, appears to be a preferred strategy to maximize longterm survival compared with waiting for a standard DBD offer, given the real risk of wait‐list mortality even for patients with low MELD scores. However, the generalization of this recommendation that all patients with MELD >15 would benefit from DCD LT should be met with extreme caution. As with any predictive model, the validity of the conclusions critically depends on the accuracy of the assumptions and stipulations that were required in constructing this model. DCD outcomes are poor in recipients with high acuity or technical complexity (redo LT) that may lead to increased cold ischemia times (CITs),11 and may be also affected by underlying diagnoses such as primary sclerosing cholangitis12 and in hepatocellular carcinoma patients with MELD exception points.13 Donor age, race, and in particular CIT and procurement warm ischemia time have all been implicated as critical factors in the development of ischemic cholangiopathy following DCD,11 with use of tissue plasminogen activator potentially mitigating this risk.16 Furthermore, the impact of center volume and experience cannot be discounted, with a recent analysis demonstrating a significant association with low center volume and high rates of biliary complications and patient mortality following DCD LT.17 This realization that DCD outcomes are inextricably linked to donor selection practices, perioperative management, and center experience poses a practical barrier to the widespread adoption of this proposal if we are to expect preservation of the more recently reported excellent outcomes with DCD LT. McLean et al. highlight the benefits of DCD LT, but extreme care must be taken not to abrogate our current excellent outcomes by suggesting that DCDs can be used in any recipient with MELD > 15. With numerous recent reports challenging the traditionally inferior results with DCD LT that undoubtedly continue to influence the avoidance of DCD organs among many transplant centers, it now is an ideal time for the development of consensus guidelines for DCD LT to define the optimal donor and recipient selection and perioperative management strategies that can truly realize the potential of DCD LT across all transplant centers.
Source: Liver Transplantation
DOI: 10.1002/lt.24756
Author: Vatche G. Agopian
Institution: University of California, Los Angeles
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2595029888