Donation after cardiac death liver transplantation: Time for policy to catch up with practice

Donation after brain death (DBD) is the predominant source of organs for transplantation, even though brain death accounts for only a small percentage of all-cause mortality in the United States. In contrast, cardiovascular death is a leading cause of mortality. Therefore, donation after cardiac death (DCD) represents an attractive strategy for remedying organ shortage and improving transplant wait-list mortality. The transplantation of DCD organs has risen dramatically over the last decade in response to federal mandates issued by the Health Resources and Services Administration and the Centers for Medicare and Medicaid Services, and 10.6% of all organ transplants currently use DCD organs. The utilization of livers from DCD donors for transplantation declined by nearly 10% from 2007 to 2008, and this decline could undermine the goal set by the Organ Donation and Transplantation Collaborative: 10% of all donors from DCD sources. This downward trend in DCD liver utilization likely stems from recent reports demonstrating inferior outcomes with DCD liver transplants versus DBD liver transplants. In particular, DCD livers are marred by higher rates of graft failure, retransplantation, and patient mortality, which are due at least in part to biliary complications (primarily ischemic cholangiopathy). In this issue of Liver Transplantation, Taner et al. report graft and patient survival data for DCD liver transplants similar to DBD liver transplants at the Mayo Clinic in Jacksonville. Although the authors should be commended for achieving such favorable outcomes, other single-institution experiences have also failed to identify differences in graft and patient survival rates between DCD and DBD livers because of limited sample sizes. The study by Taner et al. was powered to resolve a 10% or greater differential in graft survival, which is admittedly greater than the differences observed between DCD and DBD livers in many studies. Consequently, although statistical significance was not achieved, there were clearly disparate trends in graft survival for DCD and DBD grafts. A peculiar feature of this study is the fact that although DCD livers yielded an inferior graft survival rate, they were associated with a superior patient survival rate in comparison with DBD livers. Because this result could have been achieved only with aggressive retransplantation, the local availability of livers for retransplantation in Jacksonville may help to explain this outcome. Therefore, it is not clear whether these results are generalizable to other localities. Despite the debate about the relative merits of census (registry) data versus sample (single-center) data, the national registry reliably captures both retransplantation and patient mortality data because of the linkage with the Social Security Death Master File. As for issues of sample size, analyses of the national registry have clearly demonstrated worse graft survival and, more recently, worse patient survival. In a complementary manner, single-institution reports provide important insights into