Resource implications of expanding the use of donation after circulatory determination of death in liver transplantation.
In the United Kingdom, liver transplantation using donation after circulatory determination of death (DCDD) organs has increased steadily over the last few years and now accounts for 20% of UK transplant activity. The procurement of DCDD livers is actively promoted as a means of increasing the donor pool and bridging the evolving disparity between the wait-list length and the number of transplants performed. The objective of this retrospective study of a cohort of patients who were matched for age, liver disease etiology, and Model for End-Stage Liver Disease score was to determine whether differences in perioperative costs and resource utilization are associated with the use of such organs. Our results showed an increased prevalence of reperfusion syndrome in the DCDD cohort (P < 0.001), a prolonged heparin effect (P = 0.01), a greater incidence of hyperfibrinolysis (P = 0.002), longer periods of postoperative ventilator use (P = 0.03) and vasopressor support (P = 0.002), and a prolonged length of stay in the intensive therapy unit (ITU; P = 0.02). The peak posttransplant aspartate aminotransferase level was higher in the DCDD group (P = 0.007), and there was significantly more graft failure at 12 months (P = 0.03). In conclusion, we have demonstrated different perioperative and early postoperative courses for DCDD and donation after brain death (DBD) liver transplants. The overall quality of DCDD grafts is poorer; as a result, the length of the ITU stay and the need for multiorgan support are increased, and this has significant financial and resource implications. We believe that these implications require a careful real-life consideration of benefits. It is essential for DCDD not to be seen as a like-for-like alternative to DBD and for every effort to be continued to be made to increase the number of donations from brain-dead patients as a first resort.
Department of Anaesthesiology, Royal Free Hospital, London, United Kingdom. bobbroomhead@gmail.com
Robert Hayden
RH
Broomhead
Sanjiv
S
Patel
Bimbi
B
Fernando
James
J
O'Beirne
Susan
S
Mallett
D000328:Adult; D001926:Brain Death; D015331:Cohort Studies; D005260:Female; D006085:Graft Survival; D006493:Heparin / Q000378:metabolism; D006801:Humans; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D015424:Reperfusion; D040841:Resource Allocation; D012189:Retrospective Studies; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000379:methods*; D006113:United Kingdom; D014850:Waiting Lists
D006493:Heparin