DCD liver transplant in patients with a MELD over 35.

Introduction: Donation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35. Methods: We analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching. Results: In the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of <30yo independently reduced the risk of graft loss by 30% (HR, 95%CI: 0.7 (0.9-0.5), p=0.019). Retransplant status was associated with a doubled risk of adverse event (HR, 95%CI: 2.1 (1.4-3.3), p=0.001). The rejection rates at 1y were similar between DCD- and DBD-LTs, (9.3% (35/375) versus 1,541 (8.7% (1,541/17,677), respectively). Discussion: In highly selected recipient/donor pair, DCD transplantation is feasible and can achieve comparable survival to DBD transplantation. Biliary complications occurred at the expected rates. In the absence of selection, DCD-LTs outcomes remain worse than those of DBD-LTs. Introduction Donation after circulatory death donor (DCD) liver transplantation (LT) remains an underutilized option in the U.S. The use of DCD liver grafts is increasing, but overall remains low (1% in 2000, 6% in 2010, and 11% in 2020) (1). Ischemia-reperfusion injury, early allograft dysfunction and their impact on renal function and biliary complications are not well tolerated by high Model for End-Stage Liver Disease (MELD) recipients (2). We (3), and others (2, 4, 5), previously designed DCD risk scores to predict outcomes, however, the corollary is that high MELD recipients are not suitable for DCD-LT. Additionally, the resulting increase in resource utilization during recovery from transplant is a concern. Consequently, patients with a high MELD are rarely transplanted with livers from DCD donors despite the paucity of outcome data after DCD-LT in patients with a high MELD. The expectation is that a Donation after Brain Death donor (DBD) will become available within a reasonable time frame. This is, unfortunately, not always the case in regions with high median MELD at transplant, and patients with a high MELD continue to experience waitlist mortality and dropout. We previously compared the different options, including DCD, DBD, and living donors (6), and it is clear that DCDs remain an important option to consider, including for high MELD recipients. Machine preservation can be used to reduce risks of DCD-LT (7), but implementation of this resource-intensive advancement has been rationed as we await real-world outcome and resource utilization data, and alternatives to machine perfusion must be considered as part of this discussion (8). We hypothesized that select recipients with a lab MELD≥35 might tolerate increased ischemia-reperfusion and lead to acceptable morbidity/mortality, renal recovery, and biliary complications rates after DCD-LT using static cold storage. To test this hypothesis, we analyzed our local cohort of DCD-LTs in patients with MELD≥35 and compared them to matched DBD-LTs. We also compared our single-center cohort with the national DCD/DBD-LTs cohort. [ABSTRACT FROM AUTHOR]