Beyond the Concepts of Elder and Marginal in DCD Liver Transplantation: A Prospective Observational Matched-Cohort Study in the Italian Clinical Setting

Donation after circulatory determination of death (DCD) is a valuable strategy to increase the availability of grafts for liver transplantation (LT). As the average age of populations rises, the donor pool is likely to be affected by a potential increase in DCD donor age in the near future. We conducted a prospective cohort study to evaluate post-transplantation outcomes in recipients of grafts from elderly DCD donors compared with younger DCD donors, and elderly donors after brainstem determination of death (DBD). From August 2020 to May 2022, consecutive recipients of deceased donor liver-only transplants were enrolled in the study. DCD recipients were propensity score matched 1:3 to DBD recipients. One-hundred fifty-seven patients were included, 26 of whom (16.6%) were transplanted with a DCD liver graft. After propensity score matching and stratification, three groups were obtained: 15 recipients of DCD donors ≥75 years, 11 recipients of DCD donors <75 years, and 28 recipients of DBD donors ≥75 years. Short-term outcomes, as well as 12 months graft survival rates (93.3%, 100%, and 89.3% respectively), were comparable among the groups. LT involving grafts retrieved from very elderly DCD donors was feasible and safe in an experienced high-volume center, with outcomes comparable to LTs from younger DCD donors and age-matched DBD donors.

The Rule of Threes: three factors that triple the likelihood of families overriding first person consent for organ donation in the UK

Between 1 April 2012 and 31 March 2015, 263 of the 2244 families in the UK whose loved ones had registered to donate organs for transplantation after their death on the NHS Organ Donor Register chose to override this decision; an override rate of 11.7%. Multivariable logistic regression analysis was applied to data relating to various aspects of the family approach in order to identify factors associated with such overrides. The factors associated with family overrides were failure to involve the Specialist Nurse for Organ Donation in the family approach (odds ratio 3.0), donation after circulatory death (odds ratio 2.7) and Black, Asian or Minority Ethnicity (odds ratio 2.7). This highlights the need to further engage with these groups in exploring donation as an end of life choice, and suggests that there may be, from the perspective of the family, fundamental differences between donation after brainstem death and circulatory death. It further adds to the body of data linking involvement of the Specialist Nurse for Organ Donation in the family approach to improved UK consent rates.