Outcomes of transplantation of livers from donation after circulatory death donors in the UK: a cohort study

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Abstract

Objectives

Outcomes of liver transplantations from donation after circulatory death (DCD) donors may be inferior to those achieved with donation after brain death (DBD) donors. The impact of using DCD donors is likely to depend on specific national practices. We compared risk-adjusted graft loss and recipient mortality after transplantation of DCD and DBD livers in the UK.

Design

Prospective cohort study. Multivariable Cox regression and propensity score matching were used to estimate risk-adjusted HR.

Setting

7 liver transplant centres in the National Health Service (NHS) hospitals in England and Scotland.

Participants

Adults who received a first elective liver transplant between January 2005 and December 2010 who were identified in the UK Liver Transplant Audit.

Interventions

Transplantation of DCD and DBD livers.

Outcomes

Graft loss and recipient mortality.

Results

In total, 2572 liver transplants were identified with 352 (14%) from DCD donors. 3-year graft loss (95% CI) was higher with DCD livers (27.3%, 21.8% to 33.9%) than with DBD livers (18.2%, 16.4% to 20.2%). After adjustment with regression, HR for graft loss was 2.3 (1.7 to 3.0). Similarly, 3-year mortality was higher with DCD livers (19.4%, 14.5% to 25.6%) than with DBD livers (14.1%, 12.5% to 16.0%) with an adjusted HR of 2.0 (1.4 to 2.8). Propensity score matching gave similar results. Centre-specific adjusted HRs for graft loss and recipient mortality seemed to differ among transplant centres, although statistical evidence is weak (p value for interaction 0.08 and 0.24, respectively).

Conclusions

Graft loss and recipient mortality were about twice as high with DCD livers as with DBD livers in the UK. Outcomes after DCD liver transplantation may vary between centres. These results should inform policies for the use of DCD livers.

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Most cited references 32

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A comparison of propensity score methods: a case-study estimating the effectiveness of post-AMI statin use.

M. Mamdani, P. Austin (2006)

There is an increasing interest in the use of propensity score methods to estimate causal effects in observational studies. However, recent systematic reviews have demonstrated that propensity score methods are inconsistently used and frequently poorly applied in the medical literature. In this study, we compared the following propensity score methods for estimating the reduction in all-cause mortality due to statin therapy for patients hospitalized with acute myocardial infarction: propensity-score matching, stratification using the propensity score, covariate adjustment using the propensity score, and weighting using the propensity score. We used propensity score methods to estimate both adjusted treated effects and the absolute and relative risk reduction in all-cause mortality. We also examined the use of statistical hypothesis testing, standardized differences, box plots, non-parametric density estimates, and quantile-quantile plots to assess residual confounding that remained after stratification or matching on the propensity score. Estimates of the absolute reduction in 3-year mortality ranged from 2.1 to 4.5 per cent, while estimates of the relative risk reduction ranged from 13.3 to 17.0 per cent. Adjusted estimates of the reduction in the odds of 3-year death varied from 15 to 24 per cent across the different propensity score methods. Copyright (c) 2005 John Wiley & Sons, Ltd.

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Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center.

David Foley, Luis Fernandez, Glen Leverson … (2011)

This study evaluates the long-term outcomes, biliary complication rates, and risk factors for biliary complications after liver transplantation from "donation after cardiac death" (DCD) donors. Recent enthusiasm toward increased use of DCD donors' livers is mitigated by high biliary complication rates. Predictive risk factors for the development of biliary complications after DCD liver transplantation remain incompletely defined. We performed a retrospective review of 1157 "donation after brain death" (DBD) and 87 DCD liver transplants performed between January 1, 1993, and December 31, 2008. Patient and graft survivals and complication rates within the first year of transplantation were compared between DBD and DCD groups. Cox proportional hazards models were used to assess the influence of potential risk factors. Patient survival was significantly lower in the DCD group compared with the DBD group at 1, 5, 10, and 15 years (DCD: 84%, 68%, 54%, and 54% vs DBD: 91%, 81%, 67%, and 58%; P < 0.01). Graft survival was also significantly lower in the DCD group compared with the DBD group at 1, 5, 10, and 15 years (DCD: 69%, 56%, 43%, 43% vs DBD: 86%, 76%, 60%, 51%; P < 0.001). Rates of overall biliary complications (OBC) (DCD: 47% vs DBD: 26%; P < 0.01) and ischemic cholangiopathy (IC) (DCD: 34% vs DBD: 1%; P < 0.01) were significantly higher in the DCD group. Donor age [hazard ratio (HR): 1.04; P < 0.01] and donor age greater than 40 years (HR: 3.13; P < 0.01) were significant risk factors for the development of OBC. Multivariate analysis revealed that cold ischemic time (CIT) greater than 8 hours (HR: 2.46; P = 0.05) and donor age greater than 40 years (HR: 2.90; P < 0.01) significantly increased the risk of IC. Long-term patient and graft survival after DCD liver transplantation remain significantly lower but acceptable when compared with DBD liver transplantations. Donor age and CIT greater than 8 hours are the strongest predictors for the development of IC. Careful selection of younger DCD donors and minimization of CIT may limit the incidence of severe biliary complications and improve the successful utilization of DCD donors' livers.

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Liver transplantation in the United States, 1999-2008.

J Fung, Mary K Guidinger, S Pelletier … (2010)

Changes in organ allocation policy in 2002 reduced the number of adult patients on the liver transplant waiting list, changed the characteristics of transplant recipients and increased the number of patients receiving simultaneous liver-kidney transplantation (SLK). The number of liver transplants peaked in 2006 and declined marginally in 2007 and 2008. During this period, there was an increase in donor age, the Donor Risk Index, the number of candidates receiving MELD exception scores and the number of recipients with hepatocellular carcinoma. In contrast, there was a decrease in retransplantation rates, and the number of patients receiving grafts from either a living donor or from donation after cardiac death. The proportion of patients with severe obesity, diabetes and renal insufficiency increased during this period. Despite increases in donor and recipient risk factors, there was a trend towards better 1-year graft and patient survival between 1998 and 2007. Of major concern, however, were considerable regional variations in waiting time and posttransplant survival. The current status of liver transplantation in the United States between 1999 and 2008 was analyzed using SRTR data. In addition to a general summary, we have included a more detailed analysis of liver transplantation for hepatitis C, retransplantation and SLK transplantation.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2013

Publication date (Electronic): 2 September 2013

Volume: 3

Issue: 9

Electronic Location Identifier: e003287

Affiliations

[1 ]Cambridge Transplant Centre, Addenbrooke's Hospital , Cambridge, UK

[2 ]Clinical Effectiveness Unit, Royal College of Surgeons of England , London, UK

[3 ]Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London, UK

[4 ]Department of Liver Transplantation and Hepatopancreatobiliary Surgery, Queen Elizabeth Hospital , Birmingham, UK

[5 ]Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh , Edinburgh, UK

Author notes

[Correspondence to ] Dr Jan H P van der Meulen; jan.vandermeulen@ 123456lshtm.ac.uk

Article

Publisher ID: bmjopen-2013-003287

DOI: 10.1136/bmjopen-2013-003287

PMC ID: 3773642

PubMed ID: 24002984

SO-VID: da410e12-f0b6-4e4f-a43f-771050fb3bfa

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

History

Date received : 22 May 2013

Date revision received : 15 July 2013

Date accepted : 16 July 2013

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Outcomes of transplantation of livers from donation after circulatory death donors in the UK: a cohort study

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Abstract

Objectives

Design

Setting

Participants

Interventions

Outcomes

Results

Conclusions

Related collections

Regulatory T cell (Treg) therapy

Most cited references 32

A comparison of propensity score methods: a case-study estimating the effectiveness of post-AMI statin use.

Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center.

Liver transplantation in the United States, 1999-2008.

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Cited by 37

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