Introduction: The recent acuity circles (AC) liver allocation policy in the United States has increased rates of donation after circulatory death (DCD) liver transplantation. We hypothesize transplant centers with high volume DCD graft usage may have differing outcomes.

Methods: All adult DCD transplant recipients in the UNOS STAR file from Jan 11 2016 to Sept 30 2021 were included. Living liver grafts, pediatric, and non-kidney simultaneous transplantation were excluded. The top decile of DCD transplant centers by volume per year were identified. 6-month and 1-year patient and liver graft survival were compared to bottom 90% usage centers using propensity score matched fine gray regression models. Outcomes were stratified by pre-AC (1/11/2016-2/3/2020) and post-AC (2/4/2020-9/30/2020) eras. Transplant recipients that cross eras were censored on last day of the pre-AC era.

Results: 2299 DCD liver transplantation recipients were included in this study, 2012 in pre-AC and 287 in post-AC eras. High DCD volume (top decile) centers had significantly improved 6-month (HR: 0.32, 95% C.I.: 0.11-0.91, P = 0.033) and 1-year (HR: 0.42, 95% C.I.: 0.17-0.98, P = 0.043) patient survival in the post-AC era compared to bottom 90% centers by volume. No significant differences were noted in 6-month or 1-year liver graft survival in either era.

Conclusion: The top decile DCD transplantation volume center have improved 6-month and 1-year patient survival compared to lower volume centers with the introduction of the acuity circles policy in the United States.