title: Donation after cardiac death liver transplantation in primary sclerosing cholangitis: proceed with caution.
abstract: BACKGROUND
  Primary sclerosing cholangitis (PSC) patients suffer from comorbidities unaccounted for by the model for end-stage liver disease scoring system and may benefit from the increased donor organ pool provided by donation after cardiac death (DCD) liver transplantation. However, the impact of DCD transplantation on PSC graft outcomes is unknown.
  
  
  METHODS
  We studied 41,018 patients using the United Network for Organ Sharing database from 2002 through 2012. Kaplan-Meier analysis and Cox regression were used to evaluate graft survival and risk factors for graft failure, respectively.
  
  
  RESULTS
  The PSC patients receiving DCD livers (n=75) showed greater overall graft failure (37.3% vs. 20.4%, P = 0.001), graft failure from biliary complications (47.4% vs. 13.9%, P = 0.002), and shorter graft survival time (P = 0.003), compared to PSC patients receiving donation after brain death organs (n=1592). Among DCD transplants (n=1943), PSC and non-PSC patients showed similar prevalence of graft failure and graft survival time, though a trend existed toward increased biliary-induced graft failure among PSC patients (47.4 vs. 26.4%, P = 0.063). Cox modeling demonstrated that PSC patients have a positive graft survival advantage compared to non-PSC patients (hazard ratio [HR]=0.72, P < 0.001), whereas DCD transplantation increased risk of graft failure (HR = 1.28, P < 0.001). Furthermore, the interaction between DCD transplant and PSC was significant (HR = 1.76, P = 0.015), indicating that use of DCD organs impacts graft survival more in PSC than non-PSC patients.
  
  
  CONCLUSIONS
  Donation after cardiac death liver transplantation leads to significantly worse outcomes in PSC. We recommend cautious use of DCD transplantation in this population.
authors.affiliation: 1 Division of Gastroenterology and Comprehensive Transplant Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA. 2 Department of Internal Medicine, University of California at Los Angeles School of Medicine, Los Angeles, CA. 3 Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, LosAngeles, CA. 4 Department of Surgery and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Vinay
authors.initials: V
authors.lastname: Sundaram
authors.forename: Gina
authors.initials: G
authors.lastname: Choi
authors.forename: Christie Y
authors.initials: CY
authors.lastname: Jeon
authors.forename: Walid S
authors.initials: WS
authors.lastname: Ayoub
authors.forename: Nicholas N
authors.initials: NN
authors.lastname: Nissen
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Klein
authors.forename: Tram T
authors.initials: TT
authors.lastname: Tran
mesh_terms: D000328:Adult; D000368:Aged; D015209:Cholangitis, Sclerosing / Q000601:surgery*; D003643:Death; D005260:Female; D006085:Graft Survival; D006801:Humans; D016031:Liver Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D009927:Tissue and Organ Procurement