Recipient Selection in DCD Liver Transplantation

The imbalance between injury, repair, regeneration, and maintenance of normal function that occurs during liver transplantation (LT) is more pronounced in recipients of donation after circulatory death (DCD) than in donation after brain death. As a way to balance this risk, careful selection of the adequate recipient is essential. Recipients with significant metabolic needs and/or poor functional reserve, such as those with advanced liver disease (extremely high MELD), fulminant hepatic failure, cardiopulmonary dysfunction, hemodynamic instability, or fulminant hepatic failure, should, in general, be avoided when using DCD livers. For the same reasons, DCD livers should be also avoided in patients with potential complex liver transplant operations where prolonged ischemia times, excessive bleeding, or other potential operative complications could create additional metabolic stress and/or ischemic injury to the allograft compromising its functional and regenerative processes. We describe our method of patient selection based on surgical complexity. Likewise, we review the published scoring systems which try to match the best potential candidates for DCD livers and avoid futile transplants. We also review the use of DCD livers in specific recipient populations such as those who are in need of simultaneous liver-kidney transplant, those with renal dysfunction, with primary sclerosing cholangitis, and with hepatocarcinoma, and in older recipients.