N. Otajonova1, R. Ruiz2, E. Martinez2, G. McKenna2, A. Gupta2, J. Bayer2, H. Fernandez2, G. Testa2, A. Wall2 1Yale New Haven Hospital, General Surgery, New Haven, CT, USA 2Annette C. and Harold C. Simmons Transplant Institute, Abdominal Transplant, Dallas, TX, USA
Introduction:
Organ donation after circulatory death (DCD) has substantially increased in the US over the past decade. However, 30% of DCD liver grafts procured for transplantation are not utilized. Barriers to DCD liver utilization include concerns about quality, particularly the risk of ischemic cholangiopathy and retransplantation, as well as the costs associated with DCD organ acquisition. This study investigates the attitudes of the liver transplant community in the US toward DCD and identifies barriers to DCD liver utilization.
Methods:
RedCap survey of liver transplant surgical directors in the US. Respondent's demographic information, program-specific procurement variations, acceptance criteria of the liver from 6 types of DCD donors, and barriers to utilization were assessed.
Results:
24 of 101 liver transplant surgical directors responded to the survey. 96% of respondents accept DCD donors for liver transplantation. 92% accept DCD donors from attending surgeons from their centers, while only 21% accept local recovery from fellows at other centers. Most programs accept livers from thoracoabdominal NRP with cold storage (96%) while substantially fewer accept liver grafts from rapid recovery DCD donors with cold storage (67%). Figure 1 shows variables considered for liver acceptance by donor type. Other than distance (which is used by fewer centers when machine perfusion is an option), most variables are consistently applied across donor scenarios. 65% (15) of transplant centers' functional warm ischemic time starts when oxygen saturation or systolic blood pressure is less than 80 %/ mmHg, 13% (3) start at extubation, 17.4% (4) start at systolic blood pressure less than 80 mmHg, and one (4.3%) uses systolic blood pressure less than 50 mmHg. Respondents stated barriers to rapid recovery include unreliability of information and risk of ischemic cholangiopathy while the primary barrier to machine perfusion was cost.
Conclusion:
We found variability among transplant programs in DCD liver graft acceptance based on procuring surgeon, procurement technique, and storage modality. Quality and cost are the two main barriers to DCD liver utilization and the main tradeoffs between rapid recovery with static cold storage (lower cost, lower quality) and machine perfusion/NRP (higher cost, better quality).
