Liver transplant program utilization of donation after circulatory death liver grafts by procurement technique and storage modality: a survey of US liver transplant surgical directors.

Introduction: Donation after circulatory death (DCD) increased in the US over the past decade. However, 30% of DCD liver grafts procured for transplantation are not utilized. Barriers to DCD liver utilization include quality concerns, particularly the risk of ischemic cholangiopathy and retransplantation, and costs associated with DCD organ acquisition. This study investigated the attitudes of the liver transplantation community in the US toward DCD and identified barriers to DCD liver utilization. Methods: RedCap survey of liver transplantation surgical directors in the US. Results: Of 101 liver transplantation surgical directors, 24 responded to the survey, and 96% of respondents accepted DCD donors. Most programs accepted livers from thoracoabdominal normothermic regional perfusion with cold storage (96%), while substantially fewer accepted liver grafts from rapid recovery DCD donors with cold storage (67%). Sixty-five percent of transplant centers' functional warm ischemic time started when oxygen saturation or systolic blood pressure was <80%/mm Hg; 13% started at extubation, 17.4% started at systolic blood pressure <80 mm Hg, and 4.3% used a systolic blood pressure <50 mm Hg. Conclusion: We found variability among transplant programs in DCD liver graft acceptance based on procuring surgeon, procurement technique, and storage modality. Quality and cost are two main barriers to DCD liver utilization, with the main tradeoffs being between rapid recovery with static cold storage (lower cost, lower quality) and machine perfusion/normothermic regional perfusion (higher cost, better quality).