Survival Benefit of Accepting Livers From Donation After Circulatory Death Donors Older Than or Equal to 60 y in the United States

Background. Since the approval by the Food and Drug Administration of normothermic machine perfusion in September 2021, the utilization of donation after circulatory death (DCD) livers has significantly increased in the United States. Despite these advancements, acceptance of DCD livers from donors aged 60 y or older (DCD60) varies significantly among transplant centers. Methods. This study analyzed data from the United Network for Organ Sharing database, encompassing 29 327 adult liver transplant candidates offered DCD60 grafts between October 2016 and June 2024. Among these, 704 offers were accepted, and 29 074 candidates received at least 1 DCD60 offer that was ultimately declined. Three-year intention-to-treat survival was measured from accept or decline until waitlist dropout or posttransplant death. Results. At 3 y after initial decline of DCD60 livers, 53.8% received a transplant, 15.1% dropped off the waitlist, and 19.7% were removed for other reasons. Candidates who accepted DCD60 livers had significantly better 3-y intention-to-treat survival compared with those who declined (86.6% versus 74.9%, P < 0.001). In subgroup analyses, the survival benefit was significant for recipients older than 50 y and those with Model for End-Stage Liver Disease (MELD) scores ≥15 when the MELD score increased by 0 to 4 from listing to offer. Conclusions. Accepting DCD60 livers provides a clear survival benefit for appropriately selected candidates, and donor-recipient matching based on age and MELD score is crucial.