Long-term outcomes of donation after cardiac death and living donor liver transplant for primary sclerosing cholangitis
Moonka D, Kitajima T, Ivanics T, Collins K, Rizzari M, Yoshida A, Abouljoud M, and Nagai S. Long-term outcomes of donation after cardiac death and living donor liver transplant for primary sclerosing cholangitis. J Hepatol 2022; 77:S778-S779.
Background and aims: The use of donation after circulatory death (DCD) grafts is reported to be a risk factor for worse outcomes after liver transplant (LT) for primary sclerosing cholangitis (PSC) due to a higher risk of biliary complications. However, long-term outcomes comparing DCD, donation after brain death (DBD) donors, and living donor LT (LDLT) have not been fully investigated in a recent cohort. This study aims to assess outcomes of LT for PSC with each graft type.
Method: Using OPTN/UNOS data, we analyzed adult LT patients with PSC or primary biliary cholangitis (PBC) between 2002 and 2020. Patients with exception scores, multi-organ or re-transplant were excluded. One, 5, and 10-year graft survival (GS) were compared between PSC and PBC groups (as control). Next, outcomes were compared between DBD-LT, DCD-LT, and LDLT in each group. In PSC, the three types of donor grafts were compared for cause of graft loss. Finally, transplant outcomes were analyzed in an early era (2002– 2010) and late era (2011–2020). Risks were adjusted by recipient variables.
Results: 3, 946 PSC and 2, 675 PBC patients were eligible. Among PSC patients, 3, 099 (78.5%), 151 (3.8%), and 696 (17.7%) received DBD-LT, DCD-LT, and LDLT, respectively. One, 5, and 10-year GS were similar between PSC and PBC groups. In PSC, DCD-LT had significantly higher risks of 1, 5, and 10-year graft loss than DBD-LT (1-year: HR 1.87, p = 0.007, 5-year: HR 1.74, p = 0.001, 10-year: HR 1.60, p = 0.003) whereas LDLT had similar risks of 5 and 10-year graft loss. In contrast, outcomes were comparable between donor types in PBC. As a cause of graft loss, DCD-LT had a significantly higher incidence of both biliary complications and PSC recurrence than other graft types.16.5% of DCD-LT lost grafts because of PSC recurrence or biliary issues vs 4.5% for DBD-LT and 5.1% for LDLT. Incidence of re-transplant was highest in DCD-LT (DCD-LT 18.5% vs DBD-LT 10.2% vs LDLT 10.6%, p = 0.005). This finding was more prominent in the early era, whereas risks of 3- and 5-year graft loss were similar among all graft types in the late era (Figure). When comparing profiles of DCD donors for PSC between eras, CIT was shorter in late era (6.5 vs 5.2 hours, p = 0.001)(Figure Presented) whereas age and proportion of organ sharing were similar between 2 groups.
Conclusion: In PSC patients, the use of DCD grafts was associated with significantly worse post-transplant outcomes because of PSC recurrence and biliary complications. LDLT had similar outcomes to DBD-LT. However, the negative effect of DCD graftswas blunted in the more current era. The use of DCD grafts is an appropriate option for PSC with appropriate donor selection.