Is the Transplantation of Elderly and DCD Donors in Low MELD Recipients Justified: An Intent-to-treat Analysis

Thousands of people die or are removed from the liver transplant waitlist because of deterioration. One major challenge is the donor shortage. Increasing extended criteria donor (ECD) allograft usage can address this. We assessed whether transplanting ECD allografts provides a survival benefit versus remaining on the waitlist for standard allocation.

A retrospective analysis of 132 073 liver transplant recipients from 2002 to 2020 via the United National Organ Sharing database was performed. Three survival analyses were performed on model end-stage liver disease (MELD) score inclusive ranges: 8-9, 10-15, and 16-18. Within each analysis, cohorts were divided into "transplanted" or the corresponding "intent-to-treat (ITT)" category. The transplanted cohort was separated into 2 definitions of ECD allografts: donations after circulatory death and donations from donors older than 70 y, along with all-other allografts. Ten-year survival was compared between the 3 transplanted groups and the ITT group.

When adjusted for covariates, multivariable Cox proportional hazards regression analyses demonstrated that both ECD allografts and all-other allografts had better survival as compared with the ITT cohorts in each of separate analyses for MELD range 10-15 and MELD range 16-18 ( P  < 0.05).

In patients with MELD scores as low as 10, there is a survival benefit to using ECD allografts compared with those followed on an ITT basis.