Topic: E. Clinical Pediatric Surgery/Transplantation/Endocrine/Plastics Surgery
Utilization, Outcomes, and Retransplantation of Liver Allografts from Donation After Cardiac Death: Implications for Further Expansion of the Cadaver Donor Pool
Fred Selck1, Eric Grossman1, Lloyd Ratner2, John F Renz2
1New York Organ Donor Network, New York, NY;2New York Presbyterian Hospital, New York, NY
OBJECTIVE: Donation after cardiac death (DCD) for liver transplantation (LTX) has significant potential but application remains infrequent. This investigation examines DCD utilization, outcomes, and retransplantation to identify mechanisms to optimize DCD application.
METHODS: Retrospective analysis of the Scientific Registry of Transplant Recipients database from 01/02 through 04/07 identified 845DCD and 21,441non-DCD adult, initial, whole-organ, liver-only LTX. Demographic and physiologic (Model for End-Stage Liver Disease [MELD]) data were compared. Outcome measures were graft survival determined as death or retransplantation and listing for retransplantation within one-year post-LTX.
RESULTS: DCD donors were younger (p<0.001), with fewer African-American and non-caucasian race (p<0.001), and fewer deaths secondary to stroke (p <0.001). DCD recipients were older (p<0.001), with lower MELD (p<0.001), and less likely in ICU (p=0.02) or high-urgency status (p<0.001). DCD allografts were more frequently imported from another allocation region (12% vs 7% [p<0.001]). Cox regression analysis of time to DCD graft failure demonstrates higher DCD graft failure within the first 180days (20.5%DCD vs 11.5%non-DCD, [p<0.001]) with convergence thereafter. DCD listing for retransplantation and graft failure progressed continuously over180days versus 20days in non-DCD. When retransplanted, DCD recipients waited longer and received higher risk allografts (p=0.039) more often from another region. More DCD recipients remain waiting for retransplantation with fewer removed for death, clinical deterioration, or improvement.
CONCLUSIONS: DCD utilization is impeded by early outcomes and a temporally different failure pattern that limits access to retransplantation. Allocation policy that recognizes these limitations and increases access to retransplantaton is necessary for expansion of this donor population.