A multicentre outcome analysis to define global benchmarks for donation after circulatory death liver transplantation

DCD Collaborator Group, Andrea Schlegel, Marjolein van Reeven, Kristopher Croome, Alessandro Parente, Annalisa Dolcet, Jeannette Widmer, Nicolas Meurisse, Riccardo De Carlis, Amelia Hessheimer, Ina Jochmans, Matteo Mueller, Otto B van Leeuwen, Amit Nair, Koji Tomiyama, Ahmed Sherif, Mohamed Elsharif, Philipp Kron, Danny van der Helm, Daniel Borja-CachoHumberto Bohorquez, Desislava Germanova, Daniele Dondossola, Tiziana Olivieri, Stefania Camagni, Andre Gorgen, Damiano Patrono, Matteo Cescon, Sarah Croome, Rebecca Panconesi, Mauricio Flores Carvalho, Matteo Ravaioli, Juan Carlos Caicedo, George Loss, Valerio Lucidi, Gonzalo Sapisochin, Renato Romagnoli, Wayel Jassem, Michele Colledan, Luciano De Carlis, Giorgio Rossi, Fabrizio Di Benedetto, Charles M Miller, Bart van Hoek, Magdy Attia, Peter Lodge, Roberto Hernandez-Alejandro, Olivier Detry, Cristiano Quintini, Gabriel C Oniscu, Robert J Porte, Vincent E. de Meijer

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BACKGROUND: To identify the best possible outcomes in liver transplantation from donation after circulatory death donors (DCD) and to propose outcome values, which serve as reference for individual liver recipients or patient groups.

METHODS: Based on 2219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1012 low-risk, primary, adult liver transplantations with a laboratory MELD of ≤20points, receiving a DCD liver with a total donor warm ischemia time of ≤30minutes and asystolic donor warm ischemia time of ≤15minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the Comprehensive Complication Index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered.

RESULTS: Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centers. The one-year retransplant and mortality rate was 5.23% and 9.01%, respectively. Within the first year of follow-up, 51.1% of recipients developed at least one major complication (≥Clavien-Dindo-Grade-III). Benchmark cut-offs were ≤3days and ≤16days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade-III), ≤16.8% for ischemic cholangiopathy, and ≤38.9CCI points at one-year posttransplant. Comparisons with higher risk groups showed more complications and impaired graft survival, outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk.

CONCLUSIONS: Despite excellent 1-year survival, morbidity in benchmark cases remains high with more than half of recipients developing severe complications during 1-year follow-up. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups, and provide a valid comparator cohort for future clinical trials.

LAY SUMMARY: The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2219 liver transplantations following controlled DCD donation in 17 centres worldwide. The following benchmark cut-offs for the most relevant outcome parameters were developed: ICU and hospital stay: ≤3 and ≤16 days; primary non function: ≤2.5%; renal replacement therapy: ≤9.6%; ischemic cholangiopathy: ≤16.8% and anastomotic strictures ≤28.4%. One-year graft loss and mortality were defined as ≤14.4% and 9.6%, respectively. Donor and recipient combinations with higher risk had significantly worse outcomes. The use of novel organ perfusion technology achieved similar, good results in this high-risk group with prolonged donor warm ischemia time, when compared to the benchmark cohort.

Original languageEnglish
Pages (from-to)371-382
Number of pages13
JournalJournal of Hepatology
Issue number2
Early online date2021
Publication statusPublished - Feb-2022



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