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Published on: June 14, 2024
Comparisons of liver transplant from DCD outcomes in high-utilization centers versus low-utilization centers in the
Joao Lucas Lima Manzi1, Eduarda Saba Oliveira1, Sarah Rombach1
1Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, FL, United States.
Insights
High and low utilization centers show similar outcomes for Donation after Cardiac Death (DCD) liver transplants. Increased experience in high-utilization centers may compensate for more selective organ use in low-utilization centers.
Area of Science:
- Transplantation Medicine
- Hepatology
- Surgical Outcomes
Background:
- Donation after Cardiac Death (DCD) liver grafts are often perceived as inferior to Donation after Brain Death (DBD) grafts.
- Transplant centers exhibit varied approaches to DCD graft utilization, ranging from highly selective to more liberal criteria.
- This disparity raises questions regarding whether organ selection or center experience is more critical for successful DCD liver transplantation.
Purpose of the Study:
- To conduct a systematic review and meta-analysis comparing outcomes of liver transplantation using DCD grafts in centers with high versus low utilization rates.
- To investigate the impact of organ selection criteria versus the benefits of increased experience in DCD graft utilization.
Main Methods:
- Systematic literature search of PubMed, Embase, and Cochrane Library up to May 24th, 2023, adhering to PRISMA guidelines.
- Inclusion of studies on liver transplantation (LT) with controlled DCD grafts published within the last five years.
- Random-effects generalized linear mixed model analysis for patient and graft survival, with subgroup meta-analysis based on DCD utilization rates. Analysis of OPTN database for DCD utilization rates.
Main Results:
- Seven studies with 898 patients were analyzed. High-utilization centers (HUCs) and low-utilization centers (LUCs) showed no significant difference in 1-year patient survival (94.6% vs. 93.7%, p=0.84) or 1-year graft survival (90.9% vs. 89.4%, p=0.54).
- Overall 1-year patient survival was 94.5% and graft survival was 90.6%.
- Incidence of ischemic cholangiopathy was 10.3% and primary nonfunction was 1.5% across all analyzed DCD liver transplants.
Conclusions:
- No statistically significant difference in patient or graft survival was observed between high and low-utilization centers for DCD liver transplants.
- Findings suggest that the greater experience gained in high-utilization centers may effectively counterbalance the more selective organ procurement strategies employed by low-utilization centers.
- This implies that center experience is a crucial factor in optimizing outcomes with DCD liver grafts.
Purpose/Objective:
Donation after Cardiac Death (DCD) grafts are considered to be inferiors compared to Donation after Brain Death (DBD) grafts. Consequently, many transplant centers employ highly selective criteria for utilizing DCD, while others use them more liberally, potentially gaining greater expertise with this procedure. This disparity in approach raises questions about the impact of organ selection versus the benefits of increased experience with DCD organs. We performed a systematic review and meta-analysis to evaluate various outcomes in centers with high and low utilization rates of DCD.
Materials/Methods:
Electronic databases PubMed, Embase, and Cochrane Library were systematically searched up to May 24th, 2023, for studies related to liver transplantation (LT). This search was conducted in accordance with PRISMA guidelines. The inclusion criteria focused on studies involving controlled DCD published within the last five years, and reporting on at least one of the outcomes of interest. Data was extracted and analyzed using a random-effects generalized linear mixed model with a 95% confidence interval (CI). The primary outcomes assessed were patient survival and graft survival. Heterogeneity among the included studies was evaluated using the I2 test, with I2>40% considered significant, and further explored through influence analysis. Subgroup meta-analysis by DCD utilization rate was done for each outcome. An analysis of the Organ Procurement & Transplantation Network (OPTN) database was performed on October 30th to determine the DCD rates and percentiles.
Results:
Seven studies encompassing 898 patients were analyzed. In parallel, data from 151 centers were examined using the OPTN database, determining the rates of DCD utilization in each center over the past five years. Centers from the seven studies were divided into five high-utilization centers (HUC) and two low-utilization centers (LUC), with the 80th percentile (13.33% DCDs/Total LT) used as the threshold for high-utilization. Overall, the 1-year patient survival rate was 94.5% (95%CI: 92.4-96.1; I2 = 0%). HUCs had a rate of 94.6% (95%CI: 92.4-96.1; I2 = 0%), and LUCs had 93.7% (95%CI: 79.1-99.2; I2 = 0%), with a p=0.84. The overall 1-year graft survival rate was 90.6% (95% CI: 88.4-92.4; I2 = 0%). HUCs showed a 1-year graft survival of 90.9% (95%CI: 88.4-92.9; I2 = 0%), and LUCs showed 89.4% (95%CI: 83.8-93.2; I2 = 0%), p=0.54. The overall incidence of ischemic cholangiopathy was 10.3% (95% CI:7.9-13.3; I2 = 0%). The total rate of primary nonfunction was 1.5% (95% CI: 0.7-3.1%; I2 = 46%).
Conclusion:
Our findings indicate no statistical difference in outcomes between high and low-utilization centers for DCD liver transplants, possibly suggesting that the higher selection in low-utilization centers is compensated by a greater experience in high-utilization centers.
