DCD Liver Transplant: a Meta-review of the Evidence and Current Optimization Strategies

In the current era of liver transplantation (LT), there is a large discrepancy between waiting list demand and organ donor availability. Increased utilization of donation after circulatory death (DCD) donors continues to expand the donor pool and improve access; however, concerns regarding recipient outcomes have limited wider adoption of these donor livers. This review will describe the current evidence regarding recipient outcomes and strategies that may help to optimize them. Historical outcomes of DCD LT are somewhat inferior to the DBD LT, yet new emerging evidence suggests that this outcome disparity may only be marginal at most; however, ischemic cholangiopathy remains a concern. Ideal donor selection criteria and optimizing recipient operative times appear to mitigate some of this risk. Extracorporeal membrane oxygenation (ECMO), hypothermic machine perfusion (HMP), and normothermic machine perfusion (NMP) are promising strategies to further improve graft resilience and performance. Cardiac death donors continue to expand the donor pool but may carry an increased risk of biliary complications. Graft reconditioning techniques, donor selection, and recipient optimization appear to mitigate this risk; however, these strategies need further investigation before generalized adoption.