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Liver Transplantation With Donation After Cardiac Death: A Treacherous Field!  Comment on “Liver Transplantation Using Organ Donation After Cardiac Death”

Carlos O. Esquivel, MD, PhD
Arch Surg. 2011;146(9):1023. doi:10.1001/archsurg.2011.255.
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Livers from DCD are occasionally used as a means to increase the donor pool. The number of DCD liver transplants continues to be very small due at least in part to the reluctance by transplant surgeons to accept the potential risks associated with such organs, particularly biliary and vascular complications, a high retransplantation rate, and exorbitant long-term costs. Hong et al1 conducted a retrospective analysis of their experience with the use of DCD liver allografts. Their objective was to identify donor and recipient factors that predict outcomes. To do so, they developed a predictive index based on donor and recipient risk factors that allows them to group transplants in low-, intermediate-, and high-risk categories. Based on such analysis, the graft survival was good in the low-risk group, acceptable in the intermediate-risk group, and poor in the high-risk group. In the high-risk group, there were no survivors beyond 21 months after transplantation. But, it is not so simple! Statistical formulas (particularly when they are based on small sample sizes such as this series) may lead to erroneous conclusions. Some of the calculations in this UCLA series are based on 6 observations. A minor change can result in a finding not being statistically significant. However, the biggest limitation of this particular study is the inherent bias while selecting the donor and recipient criteria for the transplants. In fact, such criteria may be considered too strict by some and too lax by others. For example, one can argue that a DCD graft from someone older than 45 years may not be a good option for a certain type of patient (eg, a patient with HCV) but may be a lifesaving alternative for another patient (eg, a patient without HCV). Such a possibility and many other permutations were not addressed in this particular study. The authors' efforts to create a better path to assist the clinician with tangible criteria to mitigate the potential problems with DCD liver transplants must be commended. However, their conclusions must be acknowledged as just guidelines. Studies from large databases may identify factors, other than the ones included in this study, that may lead to improved outcomes in DCD liver transplantation. The organ donor shortage is so severe that physicians should not shy away from using DCD liver allografts. On the contrary, DCD transplantation must be encouraged. It is likely that the best solution to lower the high complication rate associated with DCD liver transplantation is to allow for a better match between donor and recipient, something that cannot be effectively done with the current organ allocation policies.

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