Background: Donation after circulatory death (DCD) for liver transplantation (LT) remain an underutilized option in the United States, especially for the sickest end-stage liver disease patients. We hypothesized that recipients with a Model for End-Stage Liver Disease (MELD) ≥35 may have acceptable outcomes after DCD-LT.

Methods: We collected and analyzed data on adult DCD recipients from the University of California, San Francisco (UCSF) cohort who had a lab-MELD of ≥35 at listing (n=41). No machine perfusion was used. We compared survival (Kaplan-Meier and Log Rank test) with our historical donation after brain death (DBD) recipients who had a lab-MELD of ≥35 at transplant (n=1,918).

Results: DCD recipient age (±SD) was 55.4 (8.8) years old, 63.4% were male, leading reasons for transplant were hepatitis C (34%) and alcoholic cirrhosis (27%). BMI (±SD) was 28.9 (6.6). All recipients were hospitalized prior to transplant, 46% were in the intensive care unit, and 51% were on renal replacement therapy at the time of transplant. 17% underwent a simultaneous liver-kidney transplant. Donor age was 31.1 (10) years, 63.4% were male, and the average BMI was 25.6 (6.8) kg/m2. Donor warm ischemia time was 21.0 (5.2) min, liver extraction time was 45.3 (19.3) min, and cold ischemia time was 7.8 (2.3) hours. The median length of stay post-transplant was 10 days. One patient out of four (26.8%) was on dialysis at discharge. DCD recipient's one-year survival was 92.3%, compared to 91.3% in DBD recipients, p=0.613 (Figure). 12.2% of the DCD recipients developed ischemic cholangiopathy.

Conclusion: DCD transplant in MELD of ≥35 recipients is feasible and can achieve similar one-year survival rates compared to DBD recipients with MELD≥35. Ischemic cholangiopathy remains present at an expected rate.