Missed Opportunities in Donation After Circulatory Death Liver Transplantation: A National Analysis of Non-Allocation...

A significant percentage of livers from DCD donors do not undergo allocation or procurement. We identified non-allocated and non-procured livers to understand reasons for non-utilization and to quantify allografts potentially suitable for transplantation.

The SRTR database was reviewed from 09/29/2021 to 12/31/2024 to identify all DCD procurements where at least one organ was transplanted. Donors were compared based on whether liver allocation and procurement occurred. Multivariable logistic regression identified independent predictors of liver allocation and procurement. Non-procured DCD livers were propensity matched to procured DCD livers based on donor characteristics to investigate potential outcomes of non-procured livers.

A total of 14 470 DCD donors had at least one organ successfully transplanted; from these, 18.7% (n = 2714) had no attempt at liver allocation (NAA). NAA livers were more likely to have elevated bilirubin and a history of heavy alcohol use. Among allocated livers, 39.2% (n = 4614) were not procured, primarily due to poor organ quality (70.5%), although logistical factors were equally as common (e.g., projected cold ischemia time, 70.4%). Non-procured liver donors were more likely to be older (>60 years: 14.7% vs. 13.5%, p < 0.01), with a withdrawal time >30 min (35.9% vs. 17.7%, p < 0.01). Despite these differences, procured-livers propensity-matched to non-procured livers had high organ utilization rates and comparable allograft survival to all other DCD livers (1-year: 90.1% vs. 90.6%, p = 0.51).

Traditionally high-risk transplanted DCD livers demonstrated comparable graft survival to other procured DCD livers. Given similar donor profile characteristics among non-procured and non-allocated livers, this suggests a potentially missed opportunity to expand the donor pool.