Abstract
Background
Heart transplantation (HTx) remains the definitive therapy for select patients with Stage D heart failure. Donation after circulatory death (DCD) has emerged as a promising strategy to expand the donor pool, with studies showing comparable survival to donation after brain death (DBD). However, little is known about how DCD impacts post-transplant quality of life. Days alive and out of the hospital (DAOH) at 1 year is a validated, patient-centered metric reflecting both post-transplant morbidity and survival.
Methods
We conducted a single-center, retrospective cohort study of 226 adult patients who underwent HTx between January 2021 and June 2023 (117 DBD and 109 DCD recipients). The primary outcome was DAOH at 1 year. Secondary outcomes included post-transplant graft function, inotrope and intensive care unit (ICU) duration, readmissions, and mortality. Baseline characteristics and outcomes were compared using appropriate statistical methods, and quantile regression was used to adjust for clinical confounders.
Results
Baseline characteristics were largely similar, although DBD recipients had higher pre-operative acuity. Median DAOH at 1 year did not differ significantly between DBD and DCD recipients (344 vs 343 days; p = 0.896). Adjusted analyses confirmed no clinically meaningful difference. Secondary outcomes, including 1-year mortality, ICU stay, and readmission rates, were also comparable.
Conclusions
In this cohort, DCD recipients achieved similar DAOH at 1 year compared to DBD recipients, supporting the use of DCD as a viable strategy in HTx. This is one of the first studies to compare post-transplant quality of life in DBD and DCD HTx recipients.
Keywords: Heart transplant, Donation after circulatory death, Donation after brain death, Days alive and out of the hospital, Quality of life
Background
Approximately 6.2 million American adults are currently diagnosed with heart failure, with the prevalence expected to increase significantly.1, 2, 3 Of these individuals, an estimated 5% eventually progress to Stage D heart failure, for which heart transplantation (HTx) becomes a necessary next step to improve both quality of life and survival.4, 5, 6 Despite the rising number of patients requiring HTx, the availability of donor hearts has been a significant limiting factor. As of May 2025, data from the United Network for Organ Sharing (UNOS) shows 3,741 individuals awaiting HTx, accentuating the mismatch between the need for donor hearts and the current donor pool.7, 8.
Traditionally, HTx has only been performed using donation after brain death (DBD). Donation after circulatory death (DCD) provides an alternative method for organ procurement that can expand the heart donor pool by approximately 30%.9 In DCD organ transplantation, organs are procured after donors have experienced irreversible cessation of circulatory and respiratory function, despite not meeting the formal definition of brain death.10 A study by Schroder et al showed similar 6-month recipient survival when comparing DBD and DCD HTx, accelerating the adoption of DCD throughout the United States and the world.11
Despite the promise of DCD for expanding donor pools, concerns about this procurement process have been raised due to an inherent ischemic insult that it inflicts upon the donor heart during an obligatory warm ischemia period, a phenomenon that is avoided in DBD.12 This is further supported by studies showing higher rates of primary early graft dysfunction (PGD) in DCD recipients compared to DBD recipients.13 However, when comparing similar DCD and DBD recipients with severe PGD, DCD recipients required shorter durations of post-HTx mechanical circulatory support (MCS) and shorter post-HTx hospital length of stay.13 Furthermore, no significant differences in survival rates or other post-HTx complications have been reported.14 Given the relatively short history of DCD HTx, there currently exists a paucity of literature exploring the significant quality of life burden faced by transplant recipients.15, 16 As the prevalence of DCD HTx increases, further studies are needed to evaluate the comparability of DBD and DCD.
Days alive and out of the hospital (DAOH) at 1 year is a validated, patient-centered outcome measure that reflects both survival and morbidity. It acts as a surrogate for quality of life and time spent in good health after a medical or surgical intervention.17, 18, 19 DAOH allows for the examination of various aspects of post-transplant recovery, including hospital readmission rate, post-operative complications, and overall functional capacity.18 This outcome measure has been validated in surgical populations,18, 20 including patients who have undergone cardiac surgery.21, 22
In this study, we aim to compare DAOH at 1 year for DCD and DBD HTx recipients at our institution, evaluating differences in patient quality of life and post-operative complications.
Methods
Design and participants
This single-center, retrospective cohort study included all consecutive patients aged ≥18 years who underwent HTx at the University of California San Diego (UCSD) between January 2021 and June 2023. The electronic health records of patients and UNOS data were reviewed individually by the study author (F.M.A.) for donor and recipient demographics, characteristics, and clinical data. Operative notes, progress notes, discharge summaries, clinic notes, and echocardiogram reports were reviewed and recorded. Study authors (A.S.B., Q.M.B., and M.A.U.) audited the collected data to confirm accuracy. This study was reviewed and approved by the Institutional Review Board of UCSD.
DCD heart transplant protocol
Two organ procurement techniques, consistent with standard protocols, are used for DCD HTx at UCSD: (1) direct procurement protocol with normothermic machine perfusion (DPP) and (2) thoraco-abdominal normothermic regional perfusion (TA-NRP). After withdrawal of life-sustaining therapy, donor organs were accepted up to 120 min for TA-NRP and up to 30 min for DPP as determined on a case-by-case basis. No changes to protocols were made throughout this study period.
Measurements
DAOH at 1 year served as the primary outcome measure of this study; DAOH calculation was performed in accordance with its previous descriptions in the literature.18, 22 Briefly, DAOH at 1 year was calculated by subtracting the number of days admitted to a hospital or acute rehabilitation unit from 365, including original transplant hospitalization days after HTx. A “day” was defined as any period ≥24 hours. Emergency department and clinic visits that lasted less than 24 hours were excluded from DAOH analysis. Patients who died during the initial HTx hospitalization were assigned a DAOH of 0. In cases of mortality within the first year of HTx after discharge from the initial transplant hospitalization, days that the patient did not survive were added to the number of days hospitalized and subtracted from 365. Through our institution’s electronic medical record, admission data from a large number of regional and national healthcare systems were also available. Through review of discharge summaries within 1 year of HTx across all available healthcare systems and results of relevant studies for graft function monitoring, we performed a comprehensive calculation of DAOH at 1 year for patients who received part of their care outside of our health system.
Secondary outcome measures that were assessed in this study include primary graft dysfunction, need for post-operative extracorporeal membrane oxygenation, post-operative intensive care unit (ICU) length of stay, number of days intubated post-HTx, number of days requiring inotropes post-HTx, left ventricular (LV) ejection fraction at 30 days and 1 year post-HTx, right ventricular function at 30 days and 1 year post-HTx, and graft rejection. Other secondary outcome measures included hospital readmission within 30 days of discharge from the index HTx hospitalization, the median length of index HTx hospitalization, the median number of days admitted at 1 year after discharge from index HTx hospitalization, and the 1-year mortality rate.
Statistical analysis
Baseline characteristics and outcome measures are presented as frequencies with percentages for categorical variables and as the median with 25th and 75th percentiles (Q1, Q3) for continuous variables. Baseline characteristics and outcome measures between those undergoing DBD versus DCD HTx were compared using either Pearson’s Chi-square test or the Fisher exact test for categorical variables. The Wilcoxon rank-sum test was used to compare continuous variables.
Review of frequencies of DAOH showed that values were right-skewed and did not normalize with log-transformation. Thus, to assess for differences in DAOH between DBD and DCD, we performed univariable and multivariable analysis using quantile regression focusing on the 10th, 25th, 50th, and 75th quantiles, as previously done.22 In our multivariable model, we adjusted for donor age, recipient age, sex mismatch between the donor and recipient, recipient pulmonary hypertension prior to transplant, inotropic support for recipients at the time of transplant, MCS for recipients at time of transplant, recipient use of a durable left ventricular assist device at time of transplant, and recipient UNOS status at time of transplant. For all results of statistical analysis, a p-value of <0.05 was considered significant. All statistical analyses were performed using IBM SPSS Statistics© version 29.0.2.0 (Armonk, NY, USA) and R statistical software version (www.rstudio.org. Accessed February 2025).
Results
Baseline characteristics
Between January 2021 and June 2023, a total of 226 patients underwent HTx at our institution, of which 117 were recipients of DBD hearts and 109 were recipients of DCD hearts (Figure 1). Of the DCD recipients, 20 received hearts using DPP and 89 received hearts using TA-NRP. Recipients of DBD and DCD hearts were of similar age (59 years [47-65] vs 62 years [54-67]; p = 0.105), body mass index (median 26.9 kg/m2 [24.1-30.3] vs median 26.9 kg/m2 [24.9-31.1]; p = 0.578), and had a similar proportion of male patients (81.2% vs 78.0%; p = 0.549). A similar proportion of DBD and DCD recipients were sensitized prior to HTx (16.2% vs 11.0%; p = 0.253). Sensitization was determined using a calculated panel-reactive antibody greater than 20%.23, 24 DBD heart recipients were higher acuity prior to undergoing HTx, with a higher proportion requiring hospitalization at the time of HTx (58.1% vs 32.0%; p < 0.001), receiving inotropes before HTx (60.7% vs 40.4%; p = 0.002), requiring support by percutaneous MCS (49.6% vs 27.5%; p < 0.001), and higher UNOS status at the time of transplant (p < 0.001).
Figure 1.
Flowchart representation of study population and subsequent outcomes of consecutive heart offers made to adult patients at UC San Diego between January 1, 2023, and June 30, 2023.
Donors of DBD and DCD HTx had similar age (median 34 years [26-42] vs median 32 years [24-39]; p = 0.124), body mass index (median 26.6 kg/m2 [23.74-30.79] vs median 26.0 kg/m2 [23.05-30.39]; p = 0.276), and a similar proportion of male patients (84.6% vs 91.7%; p = 0.099; Table 1).
Table 1.
Donor and Recipient Characteristics
| Variables | DBD (n = 117) | DCD (n = 109) | Total (n = 226) | p value | |
|---|---|---|---|---|---|
| Recipient Gender, n (%) | Male | 95 (81.2) | 85 (78.0) | 180 (79.6) | 0.549b |
| Female | 22 (18.8) | 24 (22.0) | 46 (20.4) | ||
| Recipient Age, median (IQR) | 59 (47-65) | 62 (54-67) | 60 (49-66) | 0.105d | |
| Race/Ethnicity, n (%) | Caucasian | 62 (53.0) | 63 (57.8) | 125 (55.3) | 0.637c |
| African American | 9 (7.7) | 4 (3.7) | 13 (5.7) | ||
| Hispanic/Latino | 40 (34.3) | 34 (31.1) | 74 (32.7) | ||
| Asian | 3 (2.5) | 5 (4.6) | 8 (3.5) | ||
| Other | 3 (2.5) | 3 (2.8) | 6 (2.7) | ||
| Height (cm) at Listing, median (IQR) | 175.26 (165.10-180.34) | 175.26 (170.18-177.80) | 175.26 (167.64-180.34) | 0.544d | |
| Weight (kg) at Listing, median (IQR) | 83.30 (72.00-93.30) | 82.50 (72.58-96.16) | 82.80 (72.00-94.91) | 0.645d | |
| BMI (kg/m2), median (IQR) | 26.91 (24.12-30.28) | 26.97 (24.90-31.06) | 26.94 (24.43-30.77) | 0.578d | |
| Blood Type, n (%) | A | 40 (34.2) | 40 (36.7) | 80 (35.4) | 0.237b |
| B | 20 (17.1) | 9 (8.3) | 29 (12.8) | ||
| AB | 6 (5.1) | 5 (4.6) | 11 (4.9) | ||
| O | 51 (43.6) | 55 (50.4) | 106 (46.9) | ||
| Etiology of Cardiomyopathy, n (%) | ICM | 45 (38.5) | 36 (33.0) | 81 (35.8) | 0.142c |
| NICM | 51 (43.6) | 50 (45.9) | 101 (44.7) | ||
| CHD | 7 (6.0) | 2 (1.8) | 9 (4.0) | ||
| Amyloid CM | 4 (3.4) | 11 (10.1) | 15 (6.6) | ||
| Sarcoid CM | 2 (1.7) | 2 (1.8) | 4 (1.8) | ||
| HCM | 4 (3.4) | 5 (4.6) | 9 (4.0) | ||
| Retransplant | 1 (0.8) | 3 (2.8) | 4 (1.8) | ||
| Other | 3 (2.6) | 0 (0) | 3 (1.3) | ||
| Hypertension, n (%) | 69 (58.9) | 73 (70.0) | 142 (62.8) | 0.214b | |
| Diabetes Mellitus, n (%) | 50 (42.7) | 34 (31.2) | 84 (37.2) | 0.073b | |
| Chronic Kidney Disease, n (%) | 48 (41.0) | 50 (45.9) | 98 (43.4) | 0.463b | |
| Pulmonary Hypertension, n (%) | 87 (74.4) | 79 (72.5) | 166 (73.5) | 0.668b | |
| Atrial Fibrillation or Flutter, n (%) | 59 (50.4) | 56 (51.4) | 115 (50.9) | 0.887b | |
| Stroke or TIA, n (%) | 19 (16.2) | 20 (18.3) | 39 (17.3) | 0.675b | |
| Donor Gender, n (%) | Male | 99 (84.6) | 100 (91.7) | 199 (88.1) | 0.099b |
| Female | 18 (15.4) | 9 (8.3) | 27 (11.9) | ||
| UNOS Status at Listing, n (%)e | 1 | 6 (5.1) | 0 (0.0) | 6 (2.7) | 0.006a, b |
| 2 | 37 (31.6) | 17 (15.6) | 54 (23.9) | ||
| 3 | 8 (6.8) | 6 (5.5) | 14 (6.2) | ||
| 4 | 32 (27.4) | 44 (40.4) | 76 (33.6) | ||
| 5 | 7 (6.0) | 10 (9.2) | 17 (7.5) | ||
| 6 | 27 (23.1) | 32 (29.3) | 59 (26.1) | ||
| UNOS Status at Transplant, n (%)e | 1 | 8 (6.8) | 0 (0.0) | 8 (3.5) | <0.001a, b |
| 2 | 54 (46.2) | 26 (23.9) | 80 (35.4) | ||
| 3 | 16 (13.7) | 12 (11.0) | 28 (12.4) | ||
| 4 | 21 (17.9) | 41 (37.6) | 62 (27.4) | ||
| 5 | 3 (2.6) | 9 (8.3) | 12 (5.3) | ||
| 6 | 15 (12.8) | 21 (19.3) | 36 (15.9) | ||
| Sensitization Before Transplant, n (%) | 19 (16.2) | 12 (11.0) | 31 (13.7) | 0.253b | |
| Inpatient Before Transplant, n (%) | 68 (58.1) | 35 (32.0) | 103 (45.6) | <0.001a, b | |
| Inotropes Before Transplant, n (%) | 71 (60.7) | 44 (40.4) | 115 (50.9) | 0.002a, b | |
| pMCS Before Transplant, n (%) | 66 (56.4) | 38 (34.9) | 104 (46.0) | <0.001a, b | |
| Highest Level of pMCS Before Transplant, n (%) | IABP | 34 (29.1) | 15 (13.8) | 49 (21.7) | 0.028a |
| Impella | 12 (10.3) | 2 (1.8) | 14 (6.2) | ||
| Durable VAD | 14 (12.0) | 18 (16.5) | 32 (14.2) | ||
| ECMO | 6 (5.1) | 3 (2.8) | 9 (4.0) | ||
| Donor Age, median (IQR) | 34 (26-42) | 32 (24-39) | 33 (25-41) | 0.124d | |
| Donor Height (cm), median (IQR) | 175.00 (168.00-178.00) | 177.80 (170.18-182.00) | 175.00 (170.00-180.00) | 0.020d | |
| Donor Weight (kg), median (IQR) | 81.90 (71.60 to −94.30) | 82.60 (71.50-95.00) | 82.40 (71.50-94.93) | 0.895d | |
| Donor BMI (kg/m2), median (IQR) | 26.58 (23.74-30.79) | 25.99 (23.05-30.39) | 26.41 (23.15-30.75) | 0.276d | |
| Donor Blood Type, n (%) | A | 36 (30.8) | 40 (36.7) | 76 (33.6) | 0.010a |
| B | 18 (15.4) | 4 (3.7) | 22 (9.7) | ||
| AB | 1 (0.8) | 0 (0.0) | 1 (0.4) | ||
| O | 62 (53.0) | 65 (59.6) | 127 (56.2) | ||
Abbreviations: BMI, Body Mass Index; CM, Cardiomyopathy; CHD, Congenital Heart Disease; DBD, Donation After Brain Death; DCD, Donation After Circulatory Death; DPP, Direct Procurement Protocol with Normothermic Machine Perfusion; ECMO, Extracorporeal Membrane Oxygenation; HCM, Hypertrophic Cardiomyopathy; IABP, Intra-aortic Balloon Pump; ICM, Ischemic Cardiomyopathy; IQR, Interquartile Range; N/A, Not Applicable; NICM, Non Ischemic Cardiomyopathy; pMCS, Pre-operative Mechanical Circulatory Support; TA-NRP, Thoraco-Abdominal Normothermic Regional Perfusion; TIA, Transient Ischemic Attack; UNOS, United Network for Organ Sharing; VAD, Ventricular Assist Device.
* Categorical data are presented as frequency (%) and continuous data as median (Q1, Q3).
p < 0.05
Statistical significance was determined by Chi-square test.
More than 20% of cells in this analysis have expected cell counts less than 5. Chi-square results may be invalid. Statistical significance was determined by Fisher’s exact test.
Statistical significance was determined by Wilcoxon rank-sum test.
The heart allocation status, assigned by the United Network for Organ Sharing, ranges from 1 to 6, with 1 representing the greatest urgency with regard to priority on the transplantation list.
Clinical outcomes after transplantation
DBD recipients were found to require fewer days of inotrope support post-HTx compared to DCD recipients (median 6 days [5-8] vs median 6 days [5-9]; p = 0.039). A smaller proportion of DBD recipients experienced episodes of graft rejection post-HTx when compared to DCD recipients (9.4% vs 19.3%; p = 0.036). Though not statistically significant, DBD recipients were less likely to experience severe primary graft dysfunction compared to DCD recipients (4.3% vs 10.1%; p = 0.088; Table 2). There was no significant difference in 1 year mortality (2.6% vs 4.6%; p = 0.487), hospital readmission within 30 days of discharge after HTx (23.9% vs 20.2%; p = 0.378), and ICU length of stay (median 5 days [4-8] vs median 5 days [4-7]; p = 0.715; Table 2) between DBD and DCD recipients.
Table 2.
Results
| Variable | DBD (n = 117) | DCD (n = 109) | Total (n = 226) | p value | |
|---|---|---|---|---|---|
| Moderate PGD, n (%) | 17 (14.5) | 20 (18.3) | 37 (16.4) | 0.438b | |
| Severe PGD, n (%) | 5 (4.3) | 11 (10.1) | 16 (7.1) | 0.088b | |
| ICU Length of Stay (days), median (IQR) | 5 (4-8) | 5 (4-7) | 5 (4-8) | 0.715d | |
| Days Intubated Post-Transplant, median (IQR) | 2 (2-3) | 2 (2-4) | 2 (2-3) | 0.502d | |
| Days on Inotrope Post-Transplant, median (IQR) | 6 (5-8) | 6 (5-9) | 6 (5-8) | 0.039a, d | |
| Post-operative RRT, n (%) | 22 (18.8) | 19 (17.4) | 41 (18.1) | 0.789b | |
| RV Function at 30 days Post-Transplant, n (%) | Normal | 92 (78.6) | 94 (86.2) | 186 (82.3) | 0.124b |
| Reduced | 24 (20.5) | 14 (12.8) | 38 (16.8) | ||
| LVEF at 30 days Post-Transplant, median (IQR) | 65 (60-71) | 64 (59-69) | 64 (60-70) | 0.164d | |
| RV Function at 1 year Post-Transplant, n (%) | Normal | 101 (86.3) | 80 (73.4) | 181 (80.1) | 0.206b |
| Reduced | 6 (5.1) | 10 (9.2) | 16 (7.1) | ||
| LVEF at 1 year Post-Transplant, median (IQR) | 62 (57-67) | 62 (56-67) | 62 (57-67) | 0.661d | |
| Graft Rejection, n (%) | 11 (9.4) | 21 (19.3) | 32 (14.2) | 0.036a,b | |
| In Hospital Mortality, n (%) | 3 (2.6) | 2 (1.8) | 5 (2.2) | 1.00c | |
| Readmission within 30 days, n (%) | 28 (23.9) | 22 (20.2) | 50 (22.1) | 0.378c | |
| Days Admitted Post-Transplant, median (IQR) | 16 (13-25) | 15 (13-22) | 15 (13-23) | 0.277d | |
| Days Admitted Post-Index Hospitalization, median (IQR) | 1 (0-9) | 3 (0-11) | 2 (0-9) | 0.263d | |
| 1 Year Mortality, n (%) | 3 (2.6) | 5 (4.6) | 8 (3.5) | 0.487c | |
| DAOH, median (IQR) | 344 (329-350) | 343 (330-351) | 344 (329-351) | 0.896d | |
Abbreviations: DAOH, Days Alive and Out of the Hospital; DBD, Donation After Brain Death; DCD, Donation After Circulatory Death; ECMO, Extracorporeal Membrane Oxygenation; ICU, Intensive Care Unit; IQR, Interquartile Range; LVEF, Left Ventricular Ejection Fraction; PGD, Primary Graft Dysfunction; RRT, Renal Replacement Therapy; RV, Right Ventricular.
*Categorical data are presented as frequency (%) and continuous data as median (Q1, Q3).
P < 0.05.
Statistical significance was determined by Chi-square test.
More than 20% of cells in this analysis have expected cell counts less than 5. Chi-square results may be invalid. Statistical significance was determined by Fisher’s exact test.
Statistical significance was determined by Wilcoxon rank-sum test.
DAOH in DBD versus DCD recipients
The distribution of DAOH at 1 year for DBD HTx recipients, DCD HTx recipients, and the entire study cohort is shown in Figure 2. The median DAOH at 1 year for the entire study cohort was 344 days (329-351). There was no significant difference in DAOH at 1 year between DBD and DCD HTx recipients in unadjusted analysis (median 344 days [329-350] vs median 343 days [330-351]; p = 0.896).
Figure 2.
distribution of days alive and out of the hospital at 1 year.
When comparing DAOH at 1 year and adjusting for potential confounders through quantile regression, there was a statistically significant difference at the 50th quantile (344 days vs 343 days; p = 0.050); however, this was associated with only a 1 day difference in DAOH, and correcting for multiple comparisons was not significant. When comparing the 10th quantile, DAOH at 1 year was 24 days longer for DBD recipients compared to DCD recipients, though this result did not meet statistical significance (291 days vs 267 days; p = 0.280). When comparing the 20th quantile, DAOH at 1 year was 1 day longer for DBD recipients compared to DCD recipients (320 days vs 319 days; p = 0.124).
Discussion
In this single-center, retrospective cohort study, there was no statistically significant difference in DAOH at 1 year when comparing DBD and DCD HTx. Moreover, when comparing the two groups, there were no significant differences in ICU length of stay, in-hospital mortality during original transplant hospitalization, readmission within 30 days of initial discharge, or mortality at 1 year. While numerically more recipients undergoing DCD experienced PGD than those undergoing DBD, this was not statistically significant and did not influence other outcomes like hospital length of stay or mortality. These findings further support the notion that HTx via DCD has comparable outcomes to DBD.
DAOH is a novel, patient-centered outcome that can be used as a surrogate for post-HTx quality of life.17, 18, 19 There is currently a scarcity of validated, well-developed metrics to assess quality of life in the rapidly expanding transplant population.25 A recent systematic review identified mortality, early hospital readmission, hospital length of stay, and graft survival as the most commonly studied endpoints in HTx studies.26 Though these endpoints serve an important purpose through the assessment of clinical outcomes in HTx, they incompletely capture the significant lifestyle burden that many patients face postoperatively. By incorporating survival, hospital length of stay, and post-operative complications requiring hospital readmission, DAOH provides a summary of clinically significant outcomes that impact patient quality of life.
Despite the expanded use of DAOH as a quality of life outcome in the literature, current studies addressing DAOH in HTx have largely avoided comparisons of DBD and DCD. When compared to the results of our entire study cohort, a previously published report from a single center in Germany showed a substantially shorter median DAOH at 1 year (295 days [223-322]) and higher mortality rate at 1 year (18.3%), though this study exclusively included DBD recipients.22 A recent report by Bruce et al also utilized DAOH as a primary outcome in HTx recipients and showed similar DAOH at 1 year (348 days [335-354]) and mortality at 1 year (2.6%) as compared to our study cohort, though patients in that study were grouped based on the use of MCS prior to HTx and not procurement strategy.27
Pre-operative illness severity represents a significant difference between DBD and DCD recipients included in this study. DBD recipients were much more likely to be of higher priority UNOS transplantation status at the time of transplant, with 66.7% of the cohort being assigned status 3 or above. In contrast, only 21.1% of DCD recipients were assigned a UNOS transplantation status of 3 or above. All 8 patients in the cohort assigned UNOS status 1 were DBD recipients. Furthermore, a significantly larger proportion of DBD recipients were hospitalized at the time of transplant, required inotropic support prior to transplant, and required MCS at the time of transplant. A similar discrepancy in acuity between DBD and DCD recipients was seen in a multi-center, randomized non-inferiority trial conducted by Schroder et al. In that study cohort, recipients in the DCD group were younger, less likely to be hospitalized at the time of HTx, and had lower priority UNOS transplantation status.11 Based on the higher acuity of DBD recipients in our cohort, there may be a bias toward lower DAOH at 1 year compared to DCD recipients, though we did not find a significant difference despite adjusting for illness severity. However, as previously mentioned, the median DAOH at 1 year of our entire cohort of HTx recipients was similar to that reported by another HTx center in the United States.27
Recent studies have shown an increased incidence of PGD following DCD compared with DBD HTx. Schroder et al reported an incidence of moderate or severe primary graft dysfunction of 22% in DCD patients, among whom 15% had severe PGD. DBD recipients were found to have an incidence of moderate or severe PGD of 10%, with 5% experiencing severe PGD.11 A report from a leading HTx center in the United States described an incidence of severe, biventricular PGD of 18.5% among DCD recipients as compared to 7.4% in DBD recipients (p = 0.004). However, despite the increased incidence of severe PGD, DCD recipients required shorter durations of post-operative MCS and shorter post-operative hospital length of stay when compared to DBD recipients with severe PGD.13 This finding is aligned with our results showing similar post-transplant hospital length of stay and DAOH at 1 year when comparing DBD and DCD. Furthermore, though the difference was not found to be statistically significant, we also report an increased rate of severe PGD in DCD recipients as compared to DBD recipients, consistent with previous reports.11, 13, 28, 29, 30 With the recognition of potential greater PGD with DCD, it is important to note that our institution’s practice has been earlier deployment of modalities to support the graft in cases which may not have met traditional criteria for severe PGD.
Despite an increase in DCD HTx in the United States over the past few years, there continues to be a significant incongruity between the need for donor hearts and the currently available donor pool.8., 31 The rising adoption of DCD in HTx can likely be attributed to mounting evidence of non-inferior outcomes when compared to DBD. Despite the focus on outcomes such as survival rate and graft function, very little research has been conducted on quality of life differences between DBD and DCD HTx. Through the utilization of DAOH, this study suggests comparable outcomes between the groups with regard to survival rate, hospital length of stay, and readmission rates within the first year.
Study limitations
This is a single-center study, and thus the practices of our system and patient population may not be generalizable to other populations. Our sample size is moderate to small; thus, we may have been underpowered to detect more significant differences in DAOH, though this seems less likely with such similarities in median times of DAOH in DBD and DCD groups. Given the variability in post-transplant outcomes and survival when comparing various transplant centers, the relatively low 1 year mortality rate at our institution may limit the generalizability of our results. While HTx recipients are followed very closely and it is unlikely a hospitalization would occur without our center’s knowledge, it is possible these events were missed. A single DBD HTx recipient was lost to follow-up shortly after their original transplant hospitalization for HTx, limiting the availability of their admission data or post-transplant studies. Survival and hospital admission data beyond 1 year was not available for a significant proportion of the study cohort, limiting analysis of longer term outcomes.
Conclusion
In this single-center retrospective analysis, there was no difference in DAOH at 1 year between DBD and DCD pathways for HTx. This suggests comparable outcomes with regard to post-transplant quality of life when comparing DBD and DCD. To our knowledge, this has not been shown previously in the literature. In conjunction with previous reports showing similar rates of survival, this study further substantiates the viability of DCD as a pathway for HTx and supports the view that it should be considered a part of the contemporary standard of care.
Author Contributions
F.M.A., A.S.B., Q.M.B., N.W., and M.A.U. were involved in study design, data collection, statistical analysis, manuscript writing, and manuscript revision. H.A.T., M.J.K., and V.P. were involved in manuscript revision.
Financial support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
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