title: Donation After Circulatory Death for Liver Transplantation: A Meta-Analysis on the Location of Life Support Withdrawal Affecting Outcomes.
abstract: BACKGROUND
  Liver transplantation using donation after circulatory death (DCD) donors is associated with inferior outcomes compared to donation after brain death (DBD). Prolonged donor warm ischemic time has been identified as the key factor responsible for this difference. Various aspects of the donor life support withdrawal procedure, including location of withdrawal and administration of antemortem heparin, are thought to play important roles in mitigating the effects of warm ischemia. However, a systematic exploration of these factors is important for more confident integration of these practices into a standard DCD protocol.
  
  
  METHODS
  Medline, EMBASE, and Cochrane libraries were systematically searched and 23 relevant studies identified for analysis. Donation after circulatory death recipients were stratified according to location of life support withdrawal (intensive care unit or operating theater) and use of antemortem heparin.
  
  
  RESULTS
  Donation after circulatory death recipients had comparable 1-year patient survival to DBD recipients if the location of withdrawal of life support was the operating theater, but not if the location was the intensive care unit. Likewise, the inferior 1-year graft survival and higher incidence of ischemic cholangiopathy of DCD compared with DBD recipients were improved by withdrawal in operating theater, although higher rates of ischemic cholangiopathy and worse graft survival were still observed in DCD recipients. Furthermore, administering heparin before withdrawal of life support reduced the incidence of primary nonfunction of the allograft.
  
  
  CONCLUSIONS
  Our evidence suggests that withdrawal in the operating theater and premortem heparin administration improve DCD liver transplant outcomes, thus allowing for the most effective usage of these valuable organs.
authors.affiliation: 1 Faculty of Medicine, University of New South Wales, NSW, Australia. 2 Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. 3 Sydney Medical School, University of Sydney, NSW, Australia. 4 Cardiac Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia. 5 Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 6 RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 7 Department of Surgery, Westmead Hospital, Westmead, NSW, Australia.
authors.forename: Yiming
authors.initials: Y
authors.lastname: Cao
authors.forename: Sara
authors.initials: S
authors.lastname: Shahrestani
authors.forename: Hong Chee
authors.initials: HC
authors.lastname: Chew
authors.forename: Michael
authors.initials: M
authors.lastname: Crawford
authors.forename: Peter Simon
authors.initials: PS
authors.lastname: Macdonald
authors.forename: Jerome
authors.initials: J
authors.lastname: Laurence
authors.forename: Wayne John
authors.initials: WJ
authors.lastname: Hawthorne
authors.forename: Kumud
authors.initials: K
authors.lastname: Dhital
authors.forename: Henry
authors.initials: H
authors.lastname: Pleass
mesh_terms: D001926:Brain Death; D003643:Death; D006085:Graft Survival; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D007511:Ischemia / Q000517:prevention & control; D017093:Liver Failure / Q000453:epidemiology / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods*; D012306:Risk; D012307:Risk Factors; D013997:Time Factors; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000379:methods*; D016896:Treatment Outcome; D052096:Warm Ischemia
chemical_list: D006493:Heparin