Tuesday, March 29, 2011

Donation After Cardiac Death' Worsens Liver Transplant Survival


NEW YORK (Reuters Health) - Liver transplant patients have significantly worse survival odds with grafts obtained after cardiac death instead of brain death, according to a study of U.S. data.

"Donation after cardiac death" (DCD) livers are known to have relatively poor graft survival, according to a February 19th report in the Journal of Hepatology, but studies of patient survival have only looked at small cohorts - until now.

Dr. Anton Skaro and colleagues from Northwestern University in Chicago analyzed national data from the Scientific Registry of Transplant Recipients on more than 43,000 liver transplants -- 1113 from DCD donors and 42,254 from brain death donors.

Patients who received DCD livers were generally older compared to the other patients, but they had fewer risk characteristics (lower MELD scores, less likely on life support, and less likely to be hospitalized) and more favorable transplant factors (younger donor age, shorter cold ischemia time, and lower rates of vasopressor use).

Despite these favorable features, 1- and 3-year patient survival rates were 82% and 71%, respectively, with DCD livers compared to 86% and 77% with livers obtained from after brain death (p<.0001 for survival after primary transplant).

 After adjusting for differences in donor and recipient factors, DCD recipients had a 44% higher mortality risk.

 "This increased hazard for mortality is similar in magnitude to the mortality risks of other well-known donor and recipient factors," the investigators note, including older donor age, older recipient age, and hepatitis C or hepatocellular carcinoma in the recipient.

 The mortality risks got worse, though, when DCD organs were combined with cold ischemia time greater than 12 hours (hazard ratio 1.81), shared organs (HR 1.69), hepatocellular carcinoma (HR 1.80), recipient age older than 60 (HR 1.92), and renal insufficiency (HR 1.82).

 But beggars can't be choosers.

 "Many of these patients may have not been offered a (brain death) liver, so survival results of 82% at one year and 71% at three years should be considered in light of the high mortality risks associated with remaining on the waiting list," the researchers say. "This is especially salient given that 30-day mortality is between 19% and 47% for patients with a MELD greater than 20."

 Retransplantation was required more than twice as often after DCD transplant (14.7% vs 6.8%; p<.001), but survival after retransplantation did not differ significantly according to the original graft source.

 SOURCE: http://www.bit.ly/i0pxTi

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