Donation After Circulatory Death (DCD) Liver Transplantation: Outcomes, Challenges, and Future Directions

Overview

This keynote lecture by Dr. Wojciech Polak, surgical director of liver transplantation at Erasmus MC, provides a comprehensive review of donation after circulatory death (DCD) liver transplantation, covering its historical development, transplant outcomes, biliary complications, and the physiological mechanisms underlying graft injury.

Key Clinical Topics

• History and taxonomy of DCD donation, including the Maastricht criteria
• Organ shortage and the role of DCD in expanding the donor pool
• Comparative outcomes of DCD versus donation after brain death (DBD) liver transplantation
• Biliary complications, particularly ischemic cholangiopathy
• The DCD injury cascade: warm ischemia, cold storage, and reperfusion injury

Key Learning Points

• Maastricht Category III DCD: the predominant source of DCD livers; involves controlled, planned circulatory arrest following withdrawal of life-sustaining treatment
• Maastricht Category V: a newer category applicable in countries permitting euthanasia or medically assisted dying, including Belgium, Canada, the Netherlands, and Spain
• Harvard criteria (1968): established brain death criteria, after which DBD became the primary organ source; DCD declined until interest was renewed by the 1995 Maastricht consensus conference
• Warm ischemia period: the interval following withdrawal of life support during which low-flow status occurs; should be limited to less than one hour to minimize hepatic injury
• No-touch period: typically five minutes post-circulatory arrest in most settings, but up to twenty minutes in some European countries; must be minimized
• Cold ischemia time: should be kept as short as possible; contributes to metabolite accumulation and subsequent reperfusion injury
• DCD injury cascade: sequential process involving hypoxia → ATP depletion → mitochondrial injury → metabolite accumulation → reactive oxygen species (ROS) burst → endothelial injury upon reperfusion
• Primary non-function and biliary complications are the leading causes of early graft failure in DCD transplantation
• Ischemic cholangiopathy: the most clinically significant biliary complication, driven by biliary epithelial sensitivity to warm ischemia

Clinical Data & Study Results

• Eurotransplant waiting list mortality: 14% at one year, rising to 18% at three years, underscoring ongoing organ shortage
• Overall biliary complication rate (DCD, meta-analysis): 26%, with non-anastomotic strictures (ischemic cholangiopathy) occurring in approximately 16% of recipients
• Ischemic cholangiopathy incidence: reported in up to 33–34% of patients across individual studies from Europe and North America
• Total biliary complication rate: up to 50% in some reported series across both continents
• Graft survival: consistently lower in DCD versus DBD transplantation in both US and European early experience, leading to higher retransplantation rates
• Patient survival: not significantly different between DCD and DBD in European cohorts, partly attributed to more aggressive early retransplantation practices

Practical Takeaways

• Limit the low-flow warm ischemia period to under one hour and the no-touch period to under thirty minutes to reduce biliary and graft injury
• Deploy experienced retrieval teams to minimize total warm ischemia time, as rapid procurement is critical in DCD donation
• Monitor DCD recipients closely for biliary complications, particularly ischemic cholangiopathy, which affects up to one-third of patients in some series
• Consider DCD donors as a meaningful strategy to address waiting list mortality, provided institutional expertise and protocols are in place
• Recognize that early retransplantation may be necessary and can preserve acceptable patient survival outcomes in DCD recipients with graft failure