The expanding frontier: Global use of DCD livers from donors over 60 years

Liver transplant (LT) waitlists keep growing globally. Simultaneously, donation after circulatory death (DCD) LT has evolved from a marginal to a mainstream practice, now representing a vital strategy to expand the donor pool. Historically, livers from older DCD donors (≥60 years) were regarded as high risk due to concerns about post-transplant cholangiopathy, primary non-function, and poorer long-term survival. These risks led many centers to exclude grafts from older DCD donors. Nonetheless, the adoption of dynamic preservation technologies, including in situ normothermic regional perfusion, ex situ normothermic machine perfusion, and ex situ hypothermic oxygenated perfusion modalities, has fundamentally altered this risk-benefit calculus. Contemporary data from national and multicenter registries demonstrate that older DCD grafts can reach patient and graft survival rates comparable to those of younger DCD and donation after brain death livers when dynamically recovered and/or preserved. The United Kingdom and Spain have led this growth, routinely transplanting donors in their 60s and 70s. Italy has pushed boundaries further with the successful use of nonagenarian donors under sequential perfusion protocols. The United States, historically hesitant with older DCDs, has rapidly adopted them since 2020, driven by the approval of machine perfusion and changes in organ allocation. These worldwide trends underscore a fundamental shift: advanced age alone is no longer a definitive barrier to DCD LT when combined with advanced preservation, graft assessment, and careful recipient selection.