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Original Investigation
August 5, 2020

Trends in Outcomes for Marginal Allografts in Liver Transplant

Author Affiliations
  • 1Department of Student Affairs, Baylor College of Medicine, Houston, Texas
  • 2Michael E. DeBakey Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 3Division of Abdominal Transplantation, Michael E. DeBakey Department of General Surgery, Baylor College of Medicine, Houston, Texas
  • 4Division of Gastroenterology, Nutrition, and Hepatology, Baylor College of Medicine, Houston, Texas
  • 5Liver Center, Division of Abdominal Transplantation, Department of General Surgery, Baylor College of Medicine, Houston, Texas
JAMA Surg. 2020;155(10):926-932. doi:10.1001/jamasurg.2020.2484
Key Points

Question  Do patients who receive marginal liver allografts based on parameters defined years ago have worse outcomes than patients who receive benchmark (ie, not marginal) allografts?

Findings  In this cohort, multicenter, large database study of the graft survival of 6 definitions of marginal liver allografts, all definitions of marginal allografts showed survival improvement over time, and allografts in the 90th percentile of the Donor Risk Index showed significant improvement over time. Lower cold ischemia time was a significant protective factor in all allografts.

Meaning  Results of this study suggest that older definitions of marginal allografts should be revised to expand the donor liver allograft supply pool and save more lives in the liver transplant arena.


Importance  Investigating outcomes after marginal allograft transplant is essential in determining appropriate and more aggressive use of these allografts.

Objective  To determine the time trends in the outcomes of marginal liver allografts as defined by 6 different sets of criteria.

Design, Setting, and Participants  In this cohort, multicenter study, 75 050 patients who received a liver transplant between March 1, 2002, and September 30, 2016, were retrospectively analyzed to last known follow-up (n = 55 395) or death (n = 19 655) using the United Network for Organ Sharing Database. The study period was divided into three 5-year eras: 2002-2006, 2007-2011, and 2012-2016. Kaplan-Meier survival analysis with log-rank test and Cox proportional hazards regression analysis were used to examine the allograft after transplant with marginal allografts, which were defined as 90th percentile Donor Risk Index allografts (calculated over the entire study period), donor after circulatory death allografts, national share allografts, old age (donors >70 years) allografts, fatty liver allografts, and 90th percentile Discard Risk Index allografts. Statistical analysis was performed from August to December 2019.

Main Outcomes and Measures  Allograft failure after transplant as defined by the Organ Procurement and Transplantation Network database.

Results  Among the 75 050 patients (44 394 men; mean [SD] age, 54.3 [9.9] years) in the study, Donor Risk Index, patient Model for End-stage Liver Disease scores, and balance of risk scores significantly increased over time. Multivariate Cox proportional hazards regression analysis indicated that 90th percentile Donor Risk Index allograft survival increased across the study period (2002-2006: hazard ratio, 1.41 [95% CI, 1.34-1.49]; 2007-2011: hazard ratio, 1.25 [95% CI, 1.17-1.34]; 2012-2016: hazard ratio, 1.10 [95% CI, 0.98-1.24]). Secondary definitions of marginal allografts (donor after circulatory death, national share, old age donors, fatty liver, and 90th percentile Discard Risk Index) showed similar improvements in allograft survival.

Conclusions and Relevance  The study’s findings encourage the aggressive use of liver allografts and may indicate a need for a redefinition of allograft marginality in liver transplantation.

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