Temporal Trends in Utilization and Outcomes of DCD Livers in the United States

Background. Historically, donation after circulatory death (DCD) livers were frequently discarded because of higher mortality and graft loss after liver transplantation (LT). However, the demand for LT continues to outstrip the supply of "acceptable" organs. Additionally, changes in the donor pool, organ allocation, and clinical management of donors and recipients, and improved clinical protocols might have altered post-DCD-LT outcomes. Methods. We studied 5975 recovered DCD livers using US Scientific Registry of Transplant Recipients data from 2005 to 2017, with a comparison group of 78 235 adult donation after brain death (DBD) livers recovered during the same time period. We quantified temporal trends in discard using adjusted multilevel logistic regression and temporal trends in post-LT mortality and graft loss for DCD LT recipients using adjusted Cox regression. Results. DCD livers were more likely to be discarded than DBD livers across the entire study period, and the relative likelihood of discard increased over time (adjusted odds ratio [aOR] of discard DCD versus DBD (3.85)4.45(5.14) 2005-2007, (5.22)5.87(6.59) 2015-2017) despite improving outcomes after DCD LT. Mortality risk for DCD LTs decreased in each time period (compared with 2005-2007, aHR 2008-2011 (0.72)0.84(0.97), aHR 2012-2014 (0.48)0.58(0.70), aHR 2015-2017 (0.34)0.43(0.55)), as did risk of graft loss (compared with 2005-2007, aHR 2008-2011 (0.69)0.81(0.94), aHR 2012-2014 (0.45)0.55(0.67), aHR 2015-2017 (0.36)0.45(0.56)). Conclusions. Despite dramatic improvements in outcomes of DCD LT recipients, DCD livers remain substantially more likely to be discarded than DBD livers, and this discrepancy has actually increased over time. DCD livers are underutilized and have the potential to expand the donor pool.