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Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States
Jennie H. Kwon*1, Walker Blanding1, Khaled Shorbaji1, Joseph R. Scalea2, Barry Gibney1, Prabhakar K. Baliga2, Arman Kilic1
1Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC; 2Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC

Objectives: Organ donation after circulatory death (DCD) has significantly expanded the donor pool for kidney and liver transplantation for the last two decades. DCD has been increasingly utilized for lung, and since 2019, for heart transplantation. The aim of this study was to summarize recent trends and waitlist and transplant outcomes in DCD kidney, liver, lung, and heart transplant.

Methods: The United Network for Organ Sharing registry was used to identify transplant candidates and recipients within the most recent allocation policy eras: 2014-2022 for kidney, 2016-2022 for liver, 2017-2022 for lung, and 2019-2022 for heart. For analysis of waitlist outcomes, transplant candidates ≥18 years were grouped by donor acceptance criteria for DCD versus conventional brain-dead donors (DBD) only. Propensity matching was performed, and competing-risks regression was used to model waitlist outcomes. For analysis of post-transplant outcomes, organ recipients were grouped by those receiving DCD versus DBD organs and were propensity matched. Survival was modeled using Kaplan-Meier and Cox regression analysis.

Results: Annual DCD transplant volumes have increased significantly since 1995, representing 32% of kidney, 11% of liver, 8% of lung, and 7% of heart transplants in 2021 (Fig 1). Among waitlist candidates, 99% of kidney, 82% of liver, 82% of lung, and 16% of heart candidates had donor criteria inclusive of DCD organs. Compared to other organ candidates, lung transplant candidates listed for DCD organs were the least likely to receive a DCD organ if they underwent transplant (8%). Additionally, lungs were the least frequently procured organ from DCD donors (20%). Liver transplant candidates listed for DCD organs were more likely to undergo transplantation compared to propensity-matched candidates listed for DBD only (Fig 2). Candidates for heart and liver transplant listed for DCD organs were less likely to experience death or clinical deterioration requiring waitlist inactivation compared to those listed for DBD only. Propensity-matched recipients of DCD organs demonstrated an increased risk for 1-, 3-, and 5-year mortality after liver and kidney transplant and for 1- and 3-year mortality after lung transplant (Fig 3). There was no difference in 1-year mortality between recipients of DCD versus DBD heart transplant.

Conclusions: DCD continues to expand access to organ transplantation, but still represents a small portion of transplants in the US. Although waitlist outcomes are improved for liver and heart candidates listed for DCD transplant, findings among kidney transplant candidates suggest that competition for DCD organs may diminish improvements in waitlist outcomes. Despite increased post-transplant mortality risk for all DCD transplant types except heart transplant, survival outcomes remain acceptable. Collectively, these results underscore the need for continued education and expansion of DCD utilization for transplantation in the US.

Annual transplant volumes using organ donation after circulatory death (DCD) for isolated kidney, liver, lung, and heart transplantation (upper left). Annual proportion of isolated deceased donor transplants occurring using DCD donors (upper right). Number of centers performing DCD transplant for each organ type (bottom left). Annual proportion of active transplant centers performing DCD transplant for each organ type (bottom right).

Cumulative incidence of waitlist outcomes among propensity-matched patients awaiting kidney, liver, lung, and heart transplantation, grouped by those with donor criteria listed for donation after circulatory death (DCD) organs versus those listed for non-DCD organs only. Competing outcomes included transplantation, death or clinical deterioration requiring waitlist inactivation, and waitlist inactivation for other reasons (not pictured).

Kaplan-Meier survival analysis after isolated kidney, liver, lung, and heart transplantation among propensity-matched recipients. DCD, donation after circulatory death; DBD, donation after brain death.

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