Expanding the Donor Pool: Donation
After Circulatory Death and Living Liver
Donation Do Not Compromise the
Results of Liver Transplantation
* Gonzalo Sapisochin,
* Nicolas Goldaracena,
Bettina E. Hansen,
Mark S. Cattral,
Paul D. Greig,
Ian D. McGilvray,
David R. Grant,
Medicine, Multi-Organ Transplant Program,
Anesthesia and Pain Management, and
for Liver Disease, Toronto General Hospital, and
Institute of Health Policy, Management and Evaluation, University of Toronto,
Toronto, Ontario, Canada
Because of the shortfall between the number of patients listed for liver transplantation (LT) and the available grafts, strate-
gies to expand the donor pool have been developed. Donation after circulatory death (DCD) and living donor (LD) grafts
are not universally used because of the concerns of graft failure, biliary complications, and donor risks. In order to over-
come the barriers for the implementation of using all 3 types of grafts, we compared outcomes after LT of DCD, LD,
and donation after brain death (DBD) grafts. Patients who received a LD, DCD, or DBD liver graft at the University of
Toronto were included. Between January 2009 through April 2017, 1054 patients received a LT at our center. Of these,
77 patients received a DCD graft (DCD group); 271 received a LD graft (LD group); and 706 received a DBD graft
(DBD group). Overall biliary complications were higher in the LD group (11.8%) compared with the DCD group (5.2%)
and the DBD group (4.8%; P < 0.001). The 1-, 3-, and 5-year graft survival rates were similar between the groups with
88.3%, 83.2%, and 69.2% in the DCD group versus 92.6%, 85.4%, and 84.7% in the LD group versus 90.2%, 84.2%, and
79.9% in the DBD group (P 5 0.24). Furthermore, the 1-, 3-, and 5-year patient survival was comparable, with 92.2%,
85.4%, and 71.6% in the DCD group versus 95.2%, 88.8%, and 88.8% in the LD group versus 93.1%, 87.5%, and 83% in
the DBD group (P 5 0.14). Multivariate Cox regression analysis revealed that the type of graft did not impact graft sur-
vival. In conclusion, DCD, LD, and DBD grafts have similar longterm graft survival rates. Increasing the use of LD and
DCD grafts may improve access to LT without affecting graft survival rates.
Liver Transplantation 24 779–789 2018 AASLD.
Received December 5, 2017; accepted March 13, 2018.
Liver transplantation (LT) using a donation after brain
death (DBD) organ is the standard of care for patients
with decompensated liver disease. Over the last 3
decades, the outcomes of LT have improved and the
indications have been extended.
The success of LT
has increased the demand, resulting in a severe organ
Currently, almost 15,000 patients are wait-
ing for a liver graft in the United States.
the growing gap between the number of patients on
the waiting list and a relatively static donor organ sup-
ply, mortality while on the waiting list now averages
20%-25% in most centers.
Living donor liver transplantation (LDLT) or
donation after circulatory death (DCD) grafts have
been proposed to increase the donor pool. However,
many centers are reluctant to embrace these options.
Adoption of LDLT has been limited by concerns
about the risk for living donors (LDs) and early reports
on high rates of technical complications.
Abbreviations: ALP, alkaline phosphatase; AST, aspartate aminotrans-
ferase; BMI, body mass index; CCI, comprehensive complication index;
CI, conﬁdence interval; CIT, cold ischemia time; DBD, donation
after brain death; DCD, donor after circulatory death; ERCP, endo-
scopic retrograde cholangiopancreatography; FFP, fresh frozen plasma;
FHF, fulminant hepatic failure; HAT, hepatic artery thrombosis;
HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HJ, hepati-
cojejunostomy Roux-en-Y; HR, hazard ratio; HRS, hepatorenal syn-
drome; ICU, intensive care unit; INR, international normalized ratio;
LD, living donor; LDLT, living donor liver transplantation; LT, liver
transplantation; MELD, Model for End-Stage Liver Disease;
KOLLMANN ET AL.