Impact of Donor Age in Donation After
Circulatory Death Liver Transplantation:
Is the Cutoff “60” Still of Relevance?
* Irene Scalera,
* M. Thamara P. R. Perera ,
Hynek Mergental ,
Darius F. Mirza,
and Paolo Muiesan
The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK;
National Institute for Health Research
Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK;
Department of Liver Surgery, Birmingham
Children’s Hospital National Health Service Foundation Trust, Birmingham, UK
Advanced donor age has been identiﬁed as a risk factor when combined with donor warm ischemia time (WIT), eg, in dona-
tion after circulatory death (DCD). In several countries, DCD livers older than 60 years are not considered suitable due to
concerns related to poor graft function and development of ischemic cholangiopathy. In this study, we evaluate outcomes after
DCD liver transplantation using grafts from donors older than 60 years. We analyzed outcomes after DCD liver transplanta-
tion (n 5 315), comparing donors > 60 years (n 5 93) and donors £ 60 years (n 5 222) from our center between 2005 and
2015. End points included graft function and complications and patient and graft survival. Multivariate risk analysis was per-
formed to deﬁne further key factors that predicted inferior outcome. Donor age at the cutoff 60 years failed to stratify patient
and graft survival. The rate of vascular, biliary, and overall complications was comparably low in both cohorts, and the median
comprehensive complication index was 42.7 points, independent from the donor age. Second, donor body mass index (BMI)
above a threshold of 25 kg/m
signiﬁcantly impacted on graft and patient survival at any donor age, whereas donor WIT and
cold ischemia times were not predictive for graft loss. In conclusion, older DCD donors can be successfully used for liver
transplantation with good longterm outcomes when further risk factors are limited. Additional risk is transmitted by an
increased donor BMI regardless of donor age.
Liver Transplantation 24 352–362 2018 AASLD.
Received March 28, 2017; accepted August 24, 2017.
SEE EDITORIAL ON PAGE 325
Livers from donation after circulatory death (DCD)
donors are increasingly used to overcome the general
organ shortage despite a higher risk of primary non-
function (PNF) and ischemic cholangiopathy (IC).
In the United Kingdom, the donor organ pool includes
30%-40% DCD donors.
Limitations of risk factors
and advances in graft preservation, operative techni-
ques, and immunosuppression have signiﬁcantly
improved clinical outcomes following DCD graft-
The impact of donor age in DCD liver trans-
plantation, however, remains controversial, and the
available caseload of DCD donors above certain
thresholds is small.
Additionally, most reports are
limited to short-term or midterm outcomes.
Accordingly, some countries, eg, the Netherlands, tra-
ditionally decline DCD donor livers with an age above
60 years, but others report an acceptable outcome given
that other risk factors are limited.
In the United
Kingdom, some liver transplant centers remain reluc-
tant in their acceptance of older DCD donors.
University Hospitals Birmingham (UHB) National
Health Service Foundation Trust contributes 25% of
all liver transplant activity in the United Kingdom,
Abbreviations: AST, aspartate transaminase; BAR, balance of risk;
BMI, body mass index; BTS, British Transplant Society; CAIPIRI-
NHA, controlled aliasing in parallel imaging results in higher accel-
eration; CCI, comprehensive complication index; CIT, cold ischemia
time; CS, cold storage; DCD, donation after circulatory death; DM,
diabetes mellitus; DRI, donor risk index; EAD, early allograft dys-
function; fDWIT, functional donor warm ischemia time; HAT,
hepatic artery thrombosis; HCC, hepatocellular carcinoma; IC, ische-
mic cholangiopathy; ICU, intensive care unit; IQR, interquartile
range; MELD, Model of End-Stage Liver Disease; OLT, orthotopic
liver transplantation; OR, odds ratio; PBC, primary biliary cholan-
gitis; PNF, primary nonfunction; PSC, primary sclerosing cholangi-
tis; RAI, rejection activity index; UHB, University Hospitals
Birmingham; UKELD, United Kingdom Model of End-Stage Liver
Disease; UW, University of Wisconsin; WIT, warm ischemia time.
SCHLEGEL ET AL.