SRS84 Patey Prize Entrant - Donor time to death and DCD liver transplant outcomes: challenging the dogma that shorter is better

Abstract Background In circulatory death transplantation, time to death (TTD) following withdrawal of life-sustaining treatment is unpredictable. Concerns persist that prolonged TTD can cause ischemic injury, resulting in organ non-use. This study assessed the impact of donor TTD on liver transplant outcomes and utilisation. Methods This cohort study used UNOS data (2010–2024). Multivariable regression models were used to analyse associations, and restricted cubic spline modelling to account for non-linear relationships. Simulation studies using predictive modelling and bootstrapping estimated potential increases in liver utilisation. Results Contrary to common belief, short TTD was associated with inferior 1-year graft survival and early graft loss. In contrast, prolonged TTD did not show inferior outcomes. Non-linear modelling revealed a sharp decline in utilisation once TTD exceeded just 15 min. Given the improved post-transplant outcomes in this cohort compared to short TTD, this decline represents unnecessary organ non-use. Simulation studies revealed that if the cohort with TTD 15–30 min, currently less likely to be utilised, were treated identically to TTD <10 min, there would have been a 22.8% (95% c.i.:19.9–25.8%) increase in utilisation. In the NRP cohort, TTD did not impact on post-transplant outcomes, but short TTD was associated with increased non-use, potentially due to failing viability criteria. Conclusions Short TTD is associated with inferior post-transplant outcome, challenging the dogma that shorter is better. We hypothesise that rapid TTD results from severe brainstem injury, with the resulting cytokine storm compounding ischemia. Evidence-based avoidance of TTD-based liver decline is a safe and simple approach to expand the donor pool.