Similar results after liver transplant with old and young DCD grafts

Last Updated: 2015-09-18

By Larry Hand

NEW YORK (Reuters Health) - Donor age does not affect the outcome of transplanted livers obtained after circulatory death, a new paper reports.

Livers from older donors after circulatory death (DCD) work as well as younger DCD livers, the authors found - although their graft survival rates were still inferior to rates achieved with organs procured after brain death.

But transplanting more DCD grafts could help to alleviate a shortage of donor organs and reduce the lengthy waiting times for transplant organs, the researchers say.

"In general, transplant organs from advanced donor age have poorer quality than young organs. Accordingly, it is easy to imagine that liver transplantation using aged DCD organs results in worse outcomes," Dr. Koji Hashimoto, of the Cleveland Clinic in Ohio, told Reuters Health by email.

"However, as shown in our study at Cleveland Clinic, with efforts to achieve better donor and recipient selection, aged DCD organs work as well as young DCD organs," he said.

Writing online September 8 in Liver Transplantation, Dr. Hashimoto and colleagues report that out of 1363 liver transplants done between 2005 and 2014, 92 involved a DCD graft.

"Because the use of DCD grafts is considered to be a significant risk factor for graft failure, the principle for DCD organ acceptance is to minimize the number of compounding risk factors between a prospective donor and recipient," the authors wrote.

During the study period, the upper limit for DCD donor age was 60. Other DCD graft selection criteria included donor warm ischemia time (DWIT) under 30 minutes, minimization of cold ischemia time (CIT), and macrosteatosis less than 30%.

Patients with a high Model for End-stage Liver Disease (MELD) score or those on life support were generally not candidates for DCD organs, unless the surgeon decided to use them based on medical urgency.

Recipients with a history of major upper abdominal surgery, coronary artery disease, valvular diseases, or pulmonary hypertension were also not generally candidates for DCD grafts.

When the researchers compared the DCD recipients with 92 propensity-score matched recipients of grafts donated after brain death (DBD), the DCD recipients had significantly inferior graft survival. One- and five-year graft survival rates were 82% and 66% for DCD recipients, versus 92% and 85% for DBD recipients (p=0.03).

Donor age, however, did not affect the outcomes of DCD grafts. The authors found similar one-, three-, and five-year graft survival rates in recipients of grafts from donors younger than 45 vs older donors (80%, 69%, and 66% vs. 83%, 72%, and 66%, respectively, p=0.67).

Logistic regression analysis found risk of graft failure increased with advancing age for DBD grafts, but not for DCD grafts.

The main difference between DCD and DBD grafts is the "necessity of being fast for the surgeon, and to keep the recipient stable during the procedure," Dr. Olivier Detry, of the University of Liege, Belgium, told Reuters Health by email. He was not involved in the new study but has conducted research in this area.

"The major issue is the end of life of the DCD donors," Dr. Detry said. "Is it ethical to give them some medications such as heparin (which the Cleveland clinicians used prior to withdrawing life support)? To our Belgian view, yes, but this matter differs from country to country."

Another important factor in this report is "allowing the centers to pick up a good donor candidate on the waiting list, and not letting the computer do so according to the MELD score," he said.

SOURCE: http://bit.ly/1KfhhgB

Liver Transpl 2015.