Differences in donation after circulatory determination of death (DCD) liver donor management. An international survey initiated by the international liver transplantation society (ILTS), society for the advancement of transplant anesthesia (SATA), and liver intensive care group of europe (LICAGE)

We conducted a survey to evaluate variability in determination of death and management of Donation after Circulatory Determination of Death (DCD) liver donors across different countries. 153 centers from 17 countries were included (48.4% US, 51.6% non-US). Most reported using onset of hemodynamic instability, rather than withdrawal of life-sustaining therapy (WLST), as the beginning of the waiting time for decision making related to organ acceptance (76.1% US vs. 47.1% non-US). Actual and maximum acceptable waiting times were comparable between groups (43.7 vs. 50.2 and 50.8 vs. 60.3 min, respectively), frequently exceeding limits defined by national policies. Onset of hemodynamic instability was most commonly defined using systolic blood pressure (SBP) alone (51.4% US vs. 31.6% non-US) or a combination of SBP and oxygen saturation (SpO2) (41.6% US vs. 56.6% non-US). Less commonly, centers used SpO2 (4.2% vs. 3.9%) or arrythmia alone (1.4% US vs. 0.0% non-US). Thresholds for SBP and SpO2 were similar between US and non-US centers (SBP 80 mmHg; and 80% for both). Sedation and analgesia for donor comfort was used less frequently in US centers compared to non-US centers (27.8% vs. 48.1%, p =0.02). Decision-making regarding waiting time was more commonly performed by a multidisciplinary team outside the US (26.1% vs. 52.0%). Over half of US and non-US centers reported using machine perfusion in over 50% of DCD grafts (64.9% vs. 51.9%). When used, normothermic regional perfusion cannulation was more commonly initiated after declaration of death (71.6% US vs. 62.0% non-US). These findings demonstrate substantial variability in DCD donor management. Standardization of definitions and practices, particularly with regard to exclusion of hemodynamic stability period from Warm Ischemic Time (WIT), may improve consistency in decision-making related to organ acceptance.