Avoid Rejecting Livers From Donation
After Circulatory Death Donors Based
on Donor Age Alone
SEE ARTICLE ON PAGE 352
Despite improved donation after circulatory death
(DCD) liver transplantation (LT) outcomes in the
United States over the last 15 years,
they represent only
6% of the total. There are multiple factors that contribute
to this low number. These include the following:
1. Inferior graft survival compared with donation
after brain death (DBD) donors.
2. Increased incidence of posttransplant cholangiopathy
resulting in significant morbidity and need for
However, judicious selection of DCD grafts results
in outcomes comparable with DBD grafts.
Factors potentially impacting DCD outcomes include
donor age, donor body mass index, recipient age, Model
warm ischemia time (DWIT), functional DWIT, cold
ischemia time (CIT), and retransplantation. Shorter
ischemia times, lower recipient MELD scores, and youn-
ger recipient age positively impact DCD outcomes.
The use of allografts from DCD donors <50 years with
short CIT resulted in better outcomes compared with
that seen with DBD donor livers with age 60 years in 1
Although most agree that the use of younger
DCD donor livers are more likely to yield more favorable
outcomes, the upper donor age limit for DCD liver
acceptance remains controversial.
In large national database analyses, donor age 60
years as an independent variable leads to a signiﬁcant
increase in DCD allograft failure.
A recently pub-
lished analysis of pooled national databases from the
United States and the United Kingdom also demon-
strated an increased risk of graft loss with DCD donor
livers 60 years.
In contrast, earlier single-center
analyses reveal that DCD LT outcomes using donor
livers with age >60 years are similar to those seen with
donor livers <60 years.
The reports demonstrating inferior outcomes when
using older DCD livers has likely affected physician
behavior over time. A recent analysis demonstrated a
marked reduction in the use of older DCD livers in
the United States. The percentage of DCD LTs with
livers 60 years of age decreased from 5% between
2003 and 2006 to 0.7% during the period between
2011 and 2014.
This was also evident in a recent US
multicenter report of 744 DCD LTs occurring
between 2005 and 2014 with only 28 grafts or 4.3%
recovered from donors 60 years.
How does one determine if an older DCD donor liver
is suitable for transplant? In this issue, Schlegel et al. in a
single-center analysis investigated the impact of DCD
donor age >60 years on LT outcomes.
A total of 222
recipients received DCD grafts from donors 60 years
and 93 recipients received DCD livers from donors >60
years. The authors’ practice initially was to accept DCD
grafts only from donors <60 years. However, during the
10-year period, they loosened the age limits. Their
median donor age was 28 years in 2005, whereas it was
68 years in 2015. Importantly, graft and patient survivals
did not differ between the younger and older DCD
grafts. In addition, there were no differences in biliary
complication rates including ischemic cholangiopathy
(11%) between the 2 groups. Multivariate analysis
revealed that well-known risk factors (donor age, CIT,
functional DWIT, recipient age, recipient MELD) were
not predictive of graft survival. The authors conclude that
the cutoff of 60 years may not be necessary with careful
donor and recipient selection.
Abbreviations: CIT, cold ischemia time; DBD, donation after brain
death; DCD, donation after circulatory death; DWIT, donor warm
ischemia time; LT, liver transplantation; MELD, Model for End-
Stage Liver Disease.
Address reprint requests to David P. Foley, M.D., Department of
Surgery, School of Medicine and Public Health, University of
Wisconsin, 600 Highland Avenue, CSC H4/766, Madison, WI
53792-3284. Telephone: 608-263-9903; FAX: 608-263-9903;
Received January 16, 2018; accepted January 16, 2018.
2018 by the American Association for the Study of Liver
View this article online at wileyonlinelibrary.com.
Potential conflict of interest: Nothing to report.