Donor Time to Death and DCD Liver Transplant Outcomes: Challenging the Dogma That Shorter Is Better

In circulatory death transplantation, time to death (TTD) following withdrawal of life-sustaining treatment is unpredictable. Concerns persist that prolonged TTD may cause ischemic injury, resulting in organ nonuse. We assessed the impact of donor TTD on liver transplant outcomes and utilization.

We used Organ Procurement and Transplantation Network data on adult donors after circulatory death transplants (2010-2025). Multivariable nonlinear (restricted cubic splines) regression models were used to analyze associations. Simulation studies estimated potential increases in liver acceptance rates.

In 8489 recipients, short donor TTD was associated with inferior outcome, contrary to popular belief. Prolonged TTD did not show inferior posttransplant outcomes, irrespective of whether normothermic regional perfusion (NRP) was used. Nonlinear modeling (n = 37 447) revealed a sharp decline in utilization once TTD exceeded just 15 min. Given prolonged TTD did not impact outcomes, these declines represent a missed opportunity for organ use. Simulation studies revealed that if surgeons assess organ offers from patients with TTD of 15-30 min identically to those with TTD <10 min, there would have been a 17.1% (95% confidence interval, 15.0%-19.3%) relative increase in utilization, with potentially better outcomes than current practice. In the setting of NRP, short TTD was associated with increased organ nonuse, potentially because of failed viability criteria in damaged livers.

Short TTD was associated with inferior posttransplant outcome, challenging the dogma that shorter is better. Prolonged TTD did not negatively impact posttransplant outcomes, irrespective of NRP use. These findings support expanded use of liver donors with prolonged TTD, especially in the era of NRP and advanced perfusion, where viability assessment provides an additional safeguard.