title: Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center.
abstract: OBJECTIVE
  This study evaluates the long-term outcomes, biliary complication rates, and risk factors for biliary complications after liver transplantation from "donation after cardiac death" (DCD) donors.
  
  
  BACKGROUND
  Recent enthusiasm toward increased use of DCD donors' livers is mitigated by high biliary complication rates. Predictive risk factors for the development of biliary complications after DCD liver transplantation remain incompletely defined.
  
  
  METHODS
  We performed a retrospective review of 1157 "donation after brain death" (DBD) and 87 DCD liver transplants performed between January 1, 1993, and December 31, 2008. Patient and graft survivals and complication rates within the first year of transplantation were compared between DBD and DCD groups. Cox proportional hazards models were used to assess the influence of potential risk factors.
  
  
  RESULTS
  Patient survival was significantly lower in the DCD group compared with the DBD group at 1, 5, 10, and 15 years (DCD: 84%, 68%, 54%, and 54% vs DBD: 91%, 81%, 67%, and 58%; P < 0.01). Graft survival was also significantly lower in the DCD group compared with the DBD group at 1, 5, 10, and 15 years (DCD: 69%, 56%, 43%, 43% vs DBD: 86%, 76%, 60%, 51%; P < 0.001). Rates of overall biliary complications (OBC) (DCD: 47% vs DBD: 26%; P < 0.01) and ischemic cholangiopathy (IC) (DCD: 34% vs DBD: 1%; P < 0.01) were significantly higher in the DCD group. Donor age [hazard ratio (HR): 1.04; P < 0.01] and donor age greater than 40 years (HR: 3.13; P < 0.01) were significant risk factors for the development of OBC. Multivariate analysis revealed that cold ischemic time (CIT) greater than 8 hours (HR: 2.46; P = 0.05) and donor age greater than 40 years (HR: 2.90; P < 0.01) significantly increased the risk of IC.
  
  
  CONCLUSIONS
  Long-term patient and graft survival after DCD liver transplantation remain significantly lower but acceptable when compared with DBD liver transplantations. Donor age and CIT greater than 8 hours are the strongest predictors for the development of IC. Careful selection of younger DCD donors and minimization of CIT may limit the incidence of severe biliary complications and improve the successful utilization of DCD donors' livers.
authors.affiliation: Division of Organ Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, 53792, USA. foley@surgery.wisc.edu
authors.forename: David P
authors.initials: DP
authors.lastname: Foley
authors.forename: Luis A
authors.initials: LA
authors.lastname: Fernandez
authors.forename: Glen
authors.initials: G
authors.lastname: Leverson
authors.forename: Michael
authors.initials: M
authors.lastname: Anderson
authors.forename: Joshua
authors.initials: J
authors.lastname: Mezrich
authors.forename: Hans W
authors.initials: HW
authors.lastname: Sollinger
authors.forename: Anthony
authors.initials: A
authors.lastname: D'Alessandro
mesh_terms: D000328:Adult; D000367:Age Factors; D001660:Biliary Tract Diseases / Q000453:epidemiology / Q000209:etiology* / Q000503:physiopathology; D001926:Brain Death; D015331:Cohort Studies; D003643:Death; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D015996:Survival Rate; D013997:Time Factors; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000379:methods; D014184:Transplantation, Homologous / Q000009:adverse effects / Q000379:methods; D055815:Young Adult