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Expanding the Margins: High Volume Utilization of Marginal Liver Grafts among 2000 Liver Transplants at a Single Institution
Karim J Halazun1, Ralph C Quillin2, Tomoaki Kato2, Craig R Smith2, Fabrizio Michelassi1, Benjamin Samstein1, James V Guarerra2, Robert S Brown1, Jean C Emond2
1Weill Cornell Medical College, New York, NY;2Columbia University Medical Center, New York, NY

Objective Liver transplant (LT) centers have attempted to expand the donor pool by using marginal livers (ML). National utilization of MLs is variable, and in some centers they are never used. We examined outcomes of MLs in the largest single institution series of MLs used to date and compare outcomes to standard (SL) and living donor (LD) livers.
Methods Analysis of a prospectively maintained database of LTs performed at our institution from 1998-2016. Table-1 summarizes criteria used to define ML grafts.
Results 2000 LT recipients were studied. Of these 928 (46%) met ML criteria. Table-1 summarizes the results. ML recipients were more likely to have lower MELD and have HCV or HCC. Most MLs used were from organs turned down regionally and shared nationally (69%) or donors >70 (22%). Survival of patients receiving MLs did not significantly differ from patients receiving SL grafts (p=0.08). Both ML and SL recipients had worse survival than LDs (p<0.01). Despite nearly half our recipients receiving MLs, overall survival was significantly better than national outcomes over the same time period (p=0.04). Our waitlist mortality remained significantly lower than national results (17.7% vs. 23.0% p<0.0001). Conclusions Outcomes of recipients of ML grafts at our institution are comparable to SL transplants. Despite liberal use of MLs, we have been able to exceed national survival metrics while successfully expanding the existing donor pool.
Table 1: Summary of Criteria Defining ML and Comparison of demographics and outcomes between grafts.
Marginal Liver (ML)
46.4% (n=928)
Standard Liver (SL)
37.5% (n= 749)
Living Donor Liver (LD)
15.6% (n= 312)
p-Value
ML Characteristics
•Donor Age >70205 (22.1%)NANANA
•CIT >12 Hrs58 (6.3%)NANANA
•Nationally Shared Organs640 (69%)NANANA
•DCD44 (4.7%)NANANA
•Partial Grafts91 (9.8%)NANANA
•>30% Macro-steatosis36 (3.9%)NANANA
•HCV +Ve Donor (HCV+)142 (15.3%)NANANA
•> 1 ECD Factor269 (28.5%)NANANA
Recipient Demographics
•Mean Age46.7 ±22.1yrs47.4 ±19.1 yrs47.4 ±19.1 yrs0.859
•Gender (% Male)65.4% (n=607)63.9% (n=483)55.3% (n=172)0.005
•Median MELD (IQR)16 (IQR 11-22)21 (IQR 12-34)16 (IQR 11-20)<0.001*
•Diagnosis of HCV35.2% (n=329)31.6% (n=239)20.6% (n=64)0.002
•Diagnosis of HCC27.4% (n=254)20.6% (n=156)9.3% (n=29)<0.001*
Outcomes
•Patient Survival at 1,3,5 years86%,76%,69%88%,81%,76%90%,85%,83%ML vs. SL p=0.08.
LD vs All p<0.01
Abbreviations: IQR: Interquartile Range, MELD: Model of End Stage Liver Disease, HCV: Hepatitis C, HCC: Hepatocellular carcinoma, CIT: Cold Ischemia Time, DCD: Non-Heart Beating Donor.


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