title: Improving National Results in Liver Transplantation Using Grafts From Donation After Cardiac Death Donors.
abstract: BACKGROUND
  Published reports describing the national experience with liver grafts from donation after cardiac death (DCD) donors have resulted in reservations with their widespread utilization. The present study aimed to investigate if temporal improvements in outcomes have been observed on a national level and to determine if donor and recipient selection have been modified in a fashion consistent with published data on DCD use in liver transplantation (LT).
  
  
  METHODS
  Patients undergoing DCD LT between 2003 and 2014 were obtained from the United Network of Organ Sharing Standard Transplant Analysis and Research file and divided into 3 equal eras based on the date of DCD LT: era 1 (2003-2006), era 2 (2007-2010), and era 3 (2011-2014).
  
  
  RESULTS
  Improvement in graft survival was seen between era 1 and era 2 (P = 0.001) and between era 2 and era 3 (P < 0.001). Concurrently, an increase in the proportion of patients with hepatocellular carcinoma and a decrease in critically ill patients, retransplant recipients, donor age, warm ischemia time greater than 30 minutes and cold ischemic time also occurred over the same period. On multivariate analysis, significant predictors of graft survival included: recipient age, biologic MELD score, recipient on ventilator, recipient hepatitis C virus + serology, donor age and cold ischemic time. In addition, even after adjustment for all of the aforementioned variables, both era 2 (hazard ratio, 0.81; confidence interval, 0.69-0.94; P = 0.007), and era 3 (hazard ratio, 0.61; confidence interval, 0.5-0.73; P < 0.001) had a protective effect compared to era 1.
  
  
  CONCLUSIONS
  The national outcomes for DCD LT have improved over the last 12 years. This change was associated with modifications in both recipient and donor selection. Furthermore, an era effect was observed, even after adjustment for all recipient and donor variables on multivariate analysis.
authors.affiliation: 1 Department of Transplant, Mayo Clinic, Jacksonville, FL.
authors.forename: Kristopher P
authors.initials: KP
authors.lastname: Croome
authors.forename: David D
authors.initials: DD
authors.lastname: Lee
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Keaveny
authors.forename: C Burcin
authors.initials: CB
authors.lastname: Taner
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D015992:Body Mass Index; D001926:Brain Death; D006528:Carcinoma, Hepatocellular / Q000601:surgery; D050377:Cold Ischemia; D016208:Databases, Factual; D003643:Death; D046148:Donor Selection; D005260:Female; D006085:Graft Survival; D006526:Hepatitis C / Q000601:surgery; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery; D016031:Liver Transplantation / Q000379:methods* / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D012720:Severity of Illness Index; D014019:Tissue Donors; D009927:Tissue and Organ Procurement; D014481:United States