Survival Benefit of Accepting Livers from Donation after Cardiac Death Donors Older than or Equal to 60 years in the United States

Introduction: Donation after circulatory death (DCD) donors aged ≥60 (DCD60) are underutilized in liver transplantation due to concerns about graft outcomes. Transplant centers may decline DCD60 livers expecting better offers. This study assessed the survival benefit of accepting them, focusing on candidate age and Model for End-Stage Liver Disease (MELD) score.

Methods: We analyzed the United Network for Organ Sharing database (January 2010–June 2024), identifying 30,503 adult candidates offered a DCD60 liver. Waitlist outcomes after DCD60 decline were evaluated. For survival benefit, we matched 632 DCD60 recipients to 14,337 candidates appearing 33,554 times in the declined offer pool within two MELD points of the recipient's allocation MELD. Kaplan-Meier curves, log-rank tests, and multivariate Cox regression were employed, with subgroups stratified by candidate age (<50, 50-59, ≥60) and allocation MELD (<15, 15-24, ≥25).

Results: DCD60 liver utilization increased, exceeding 30% in 2024. Five years after initial DCD60 decline, 55.9% received a transplant, and 17.2% died without transplantation. In the matched population, DCD60 recipients showed better five-year survival than decliners (76.0% vs. 65.5%, p<0.001; adjusted hazard ratio 0.58, p<0.001). Stratified analysis indicated a significant benefit for candidates aged ≥50 and with MELD 15–24, but not for candidates aged <50 or with MELD <15 or ≥25.

Conclusion: Accepting DCD60 livers provides a significant survival benefit, particularly for candidates aged ≥50 or with MELD 15-24. These findings support broader utilization of DCD60 livers, with appropriate candidate selection. Younger or low-MELD candidates may benefit from waiting for non-DCD60 offers due to lower waitlist mortality.