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• W1992775129 abstract "We would like to thank Dr. Freeman for his interest in our article. Demonstrating a survival benefit after transplantation is the objective for any allograft recipient. In the absence of compiled data for mortality rates on waitlisted candidates within or across defined risk groups, interim decisions on donation after cardiac death (DCD) donor-candidate pairs must be made based on available information from posttransplant DCD cases. In our report, stratified outcomes were demonstrated for particular DCD donor-candidate categories, and our conclusions were congruent with those arrived at by others in examining outcomes from the use of high-risk allografts (1Stratta RJ Rohr MS Sundberg AK et al.Intermediate-term outcomes with expanded criteria deceased donors in kidney transplantation: A spectrum or specter of quality?.Ann Surg. 2006; 243: 594-601Crossref PubMed Scopus (100) Google Scholar). With feasibility demonstrated, acceptable outcomes will require consensus, and subsequent analyses for survival benefits can be determined within defined categories. As our understanding of the biology and effects of (circulatory) warm ischemia prior to cold storage remains incomplete (2Monbaliu D, Crabbe T, Roskams T, Fevery J, Verwaest C, Pirenne J. Livers from non-heart-beating donors tolerate short periods of warm ischemia. Transplantation 1226; 79: 1226–1230.Google Scholar), the assumption that recipient risk factors have comparable effects on DCD and donation after brain death (DBD) grafts may limit any conclusions from such an analysis. Applying the RCRR’s risk factors to recipients of DBD donors would provide information on graft survival regarding selected parameters within the equation. The consequences of doing so is less certain, since available studies have provided familiar and generally agreed upon recipient risk factors affecting graft survival of livers from DBD donors (3Moore DE Feurer ID Speroff T et al.Impact of donor, technical, and recipient risk factors on survival and quality of life after liver transplantation.Arch Surg. 2005; 140: 273-277Crossref PubMed Scopus (85) Google Scholar). If performed, however, a comparative analysis between DBD and DCD recipients using similar candidate risk categories would result in DBD recipients having outcomes that were inferior, similar, or superior, to those of DCD recipients. If either of the latter two conditions were true, then DCD donors would not be at any ‘higher risk’ than DBD donors, independent of the recipient-donor pairing category. Current evidence support the greater likelihood of inferior DCD recipient outcomes (4Bernat JL D'Alessandro AM Port FK et al.Report of a national conference on donation after cardiac death.Am J Transplant. 2006; 6: 281-291Abstract Full Text Full Text PDF PubMed Scopus (454) Google Scholar), and the clinician is thus faced with the question of balancing a patient survival benefit against optimizing graft utilization. In a donor-limited environment, the acuity and gravity of such decisions are most notable in programs and UNOS (United Network for Organ Sharing) regions where recipient Model for End-Stage Liver Disease (MELD) scores approach 40 at the time of transplantation (although we acknowledged that the current data were insufficient for valid correlation with MELD scores). The algorithm and conclusions in the manuscript were intended to assist in these decisions, and not replace sound judgment and reflection on individual conditions with results from conglomerate analyses. It is not meant to be exclusionary, and we agree with Dr. Freeman and have also reported that higher risk candidates can be transplanted with higher risk grafts (5Matsuoka L Jabbour N Selby R Singh G Successful transplantation of DCD liver in recipient with MELD score of 40.Transplantation. 2006; 82: 716Crossref Scopus (1) Google Scholar). Amidst continuing reports of suboptimal outcomes in DCD donors (6Foley DP Fernandez LA Leverson G et al.Donation after cardiac death: The University of Wisconsin experience with liver transplantation.Ann Surg. 2005; 242: 724-731Crossref PubMed Scopus (322) Google Scholar), the emphasis of our article and our suggestion on policy is to endorse and encourage a continued and increased effort to use DCD liver allografts. We agree with Dr. Freeman that further study and analyses of DCD and DBD recipient risk factors are necessary in order to optimize patient and graft outcomes and to demonstrate a survival benefit from the use of such grafts." @default.
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• W1992775129 date "2007-01-01" @default.
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• W1992775129 title "Utility Versus Utilization of DCD Liver Allografts" @default.
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• W1992775129 doi "https://doi.org/10.1111/j.1600-6143.2006.01628.x" @default.
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