Risk scores for allograft failure: Are they still useful in liver recipients from donation after circulatory death?

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<meta name="dc.publisher" content="Baishideng Publishing Group Inc." /> <meta name="dc.date" content="Dec 18, 2024" /> <meta name="dc.identifier" content="doi:10.5500/wjt.v14.i4.97612" /> <meta name="dc.creator" content="Mohamed H Mohamed Chairi" /> <meta name="dc.creator" content="Mónica Mogollón González" /> <meta name="dc.creator" content="Jennifer Triguero Cabrera" /> <meta name="dc.creator" content="Inmaculada Segura Jiménez" /> <meta name="dc.creator" content="Maria T Villegas Herrera" /> <meta name="dc.creator" content="Jesús M Villar del Moral" /> <meta name="citation_journal_title" content="World Journal of Transplantation" /> <meta name="citation_authors" content="Mohamed H Mohamed Chairi, Mónica Mogollón González, Jennifer Triguero Cabrera, Inmaculada Segura Jiménez, Maria T Villegas Herrera, Jesús M Villar del Moral" /> <meta name="citation_title" content="Risk scores for allograft failure: Are they still useful in liver recipients from donation after circulatory death?" /> <meta name="citation_publication_date" content="Dec 18, 2024" /> <meta name="citation_volume" content="14" /> <meta name="citation_issue" content="4" /> <meta name="citation_doi" content="10.5500/wjt.v14.i4.97612" /> <meta name="citation_pdf_url" content="" /> <meta name="citation_fulltext_html_url" content="https://www.wjgnet.com/2220-3230/full/v14/i4/97612.htm" /> <title>Risk scores for allograft failure: Are they still useful in liver recipients from donation after circulatory death?</title> <link href="/Content/css?v=98xd4-SmS2AY1APxJ_FklgIV5DVdyM8ywpN6sUUkpc41" rel="stylesheet"/> <script src="/bundles/modernizr?v=wBEWDufH_8Md-Pbioxomt90vm6tJN2Pyy9u9zHtWsPo1"></script> <link href="/Content/articlecss?v=B5Z6RLYvIpJ8pTgIwEaJ8SUz5Sg05EkXwm31CAIQFH81" rel="stylesheet"/> <script src="/bundles/jquery?v=FVs3ACwOLIVInrAl5sdzR2jrCDmVOWFbZMY6g6Q0ulE1"></script> </head> <body> <input id="sitename" name="sitename" type="hidden" value="2220-3230" /> <div class="siteBody"> <div class="main cl"> 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</div> </div> <div class="left-collapse cl"> <div class="sectiontitle cl" onclick="ShowDetail('cimg6');"> <div class="sectionimg fl"> <img style="border:0;" alt="" id="cimg6" src="https://www.f6publishing.com/contents/images/collapsed_yes.gif" /> </div> <div class="sectiontext fl"> <span> Corresponding Author of This Article </span> </div> </div> <div class="sectioncontent cl" id="cimg6div" style="display:none;"> <span>Mohamed H Mohamed Chairi, PhD, Doctor, Medical Assistant, Surgeon, Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Fuerzas Armadas Av. No. 2, Granada 18013, Andalusia, Spain. <NewLine /><email>yasinmc1994@gmail.com</email></span> </div> </div> <div class="left-collapse cl"> <div class="sectiontitle cl" onclick="ShowDetail('cimg10');"> <div class="sectionimg fl"> <img style="border:0;" alt="" id="cimg10" src="https://www.f6publishing.com/contents/images/collapsed_yes.gif" /> </div> <div class="sectiontext fl"> <span> Research Domain of This Article </span> </div> </div> <div class="sectioncontent cl" id="cimg10div" style="display:none;"> <span>Transplantation</span> </div> </div> <div class="left-collapse cl"> <div class="sectiontitle cl" onclick="ShowDetail('cimg11');"> <div class="sectionimg fl"> <img style="border:0;" alt="" id="cimg11" src="https://www.f6publishing.com/contents/images/collapsed_yes.gif" /> </div> <div class="sectiontext fl"> <span> Article-Type of This Article </span> </div> </div> <div class="sectioncontent cl" id="cimg11div" style="display:none;"> <span>Retrospective Study</span> </div> </div> <div class="left-collapse cl"> <div class="sectiontitle cl" onclick="ShowDetail('cimg12');"> <div class="sectionimg fl"> <img style="border:0;" alt="" id="cimg12" src="https://www.f6publishing.com/contents/images/collapsed_yes.gif" /> </div> <div class="sectiontext fl"> <span> Open-Access Policy of This Article </span> </div> </div> <div class="sectioncontent cl" id="cimg12div" style="display:none;"> <span>This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. 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series, Figures (1-1) series, Tables (1-3) series." style="display:block;" /> </div><script id="dxss_529238874">  </script> </div> <div class="articlestatis"> <script id="dxis_215128587" src="/DXR.axd?r=1_19,1_213,1_224,1_225,1_211,1_227,1_236,1_238,1_239,1_230,1_234,1_240,17_48,17_2-8NNPn"></script><table class="dxgvControl dxgv" id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9" style="width:215px;border-collapse:separate;"> <tr> <td style="padding-left:0px;padding-right:0px;padding-top:0px;padding-bottom:0px;"><table id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXMainTable" class="dxgvTable dxgvRBB" oncontextmenu="return ASPx.GVContextMenu('gvStatis705bb305-0163-4f48-bfdf-eebd576094d9',event);" style="width:100%;empty-cells:show;"> <tr id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXHeadersRow0"> <td id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_col0" class="dxgvHeader" style="width:150px;border-top-width:0px;border-left-width:0px;"><table style="width:100%;"> <tr> <td>Item</td><td style="width:1px;text-align:right;"><span class="dx-vam"> </span></td> </tr> </table></td><td id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_col1" class="dxgvHeader" style="border-top-width:0px;border-left-width:0px;border-right-width:0px;"><table style="width:100%;"> <tr> <td>Count</td><td style="width:1px;text-align:right;"><span class="dx-vam"> </span></td> </tr> </table></td> </tr><tr id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXDataRow0" class="dxgvDataRow"> <td class="dxgv">PDF</td><td class="dxgv dx-ar" style="border-right-width:0px;">32</td> </tr><tr id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXDataRow1" class="dxgvDataRow"> <td class="dxgv">HTML</td><td class="dxgv dx-ar" style="border-right-width:0px;">662</td> </tr><tr id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXDataRow2" class="dxgvDataRow"> <td class="dxgv">Figures (1-1)</td><td class="dxgv dx-ar" style="border-right-width:0px;">190</td> </tr><tr id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXDataRow3" class="dxgvDataRow"> <td class="dxgv">Tables (1-3)</td><td class="dxgv dx-ar" style="border-right-width:0px;">209</td> </tr><tr id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_DXFooterRow" class="dxgvFooter"> <td class="dxgv" style="border-bottom-width:0px;"> </td><td class="dxgv" style="text-align:Right;border-right-width:0px;border-bottom-width:0px;">Sum=1093</td> </tr> </table><table id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_LP" class="dxgvLoadingPanel" style="left:0px;top:0px;z-index:30000;display:none;"> <tr> <td class="dx" style="padding-right:0px;"><img class="dxlp-loadingImage dxlp-imgPosLeft" src="/DXR.axd?r=1_89-2NNPn" alt="" style="vertical-align:middle;" /></td><td class="dx" style="padding-left:0px;"><span id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_TL">Loading…</span></td> </tr> </table><div id="gvStatis705bb305-0163-4f48-bfdf-eebd576094d9_LD" class="dxgvLoadingDiv" 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class="dx-vam"> </span></td> </tr> </table></td><td id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_col1" class="dxgvHeader" style="border-top-width:0px;border-left-width:0px;border-right-width:0px;"><table style="width:100%;"> <tr> <td>Count</td><td style="width:1px;text-align:right;"><span class="dx-vam"> </span></td> </tr> </table></td> </tr><tr id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_DXDataRow0" class="dxgvDataRow"> <td class="dxgv">Browse</td><td class="dxgv dx-ar" style="border-right-width:0px;">55</td> </tr><tr id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_DXDataRow1" class="dxgvDataRow"> <td class="dxgv">Download</td><td class="dxgv dx-ar" style="border-right-width:0px;">155</td> </tr><tr id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_DXFooterRow" class="dxgvFooter"> <td class="dxgv" style="border-bottom-width:0px;"> </td><td class="dxgv" style="text-align:Right;border-right-width:0px;border-bottom-width:0px;">Sum=210</td> </tr> </table><table id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_LP" class="dxgvLoadingPanel" style="left:0px;top:0px;z-index:30000;display:none;"> <tr> <td class="dx" style="padding-right:0px;"><img class="dxlp-loadingImage dxlp-imgPosLeft" src="/DXR.axd?r=1_89-2NNPn" alt="" style="vertical-align:middle;" /></td><td class="dx" style="padding-left:0px;"><span id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_TL">Loading…</span></td> </tr> </table><div id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_LD" class="dxgvLoadingDiv" style="display:none;z-index:29999;position:absolute;"> </div><img id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_IADD" class="dxGridView_gvDragAndDropArrowDown" src="/DXR.axd?r=1_89-2NNPn" alt="Down Arrow" style="position:absolute;visibility:hidden;top:-100px;" /><img id="gvStatis2e8a29f9-9995-42f4-9ae5-4c6acf4ec13e_IADU" class="dxGridView_gvDragAndDropArrowUp" src="/DXR.axd?r=1_89-2NNPn" alt="Up Arrow" style="position:absolute;visibility:hidden;top:-100px;" /><img 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</div> </div> <div class="left-collapse cl"> <div class="sectiontitle cl"> <div class="sectiontext fl"> <span> Journal Information of This Article </span> </div> </div> <div class="sectioncontent cl"> <div class="infotitle"> Publication Name </div> <div class="infocontent"> <i>World Journal of Transplantation</i> </div> <div class="infotitle"> ISSN </div> <div class="infocontent"> 2220-3230 </div> <div class="infotitle"> Publisher of This Article </div> <div class="infocontent"> Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA </div> <br /> </div> </div> </div> <div class="infopart fr"> <link rel="stylesheet" href="/DXR.axd?r=1_74,1_68,1_69,1_70,1_73,1_210,1_207-2NNPn" /><link rel="stylesheet" href="/DXR.axd?r=1_209,1_206,1_254,1_253,1_84-2NNPn" /> <script id="dxis_1324860310" src="/DXR.axd?r=1_11,1_252,1_64,1_12,1_13,1_14,1_15,1_16,1_20,1_66,1_48,1_17,1_9,17_0,17_7,1_27,1_39,1_31,17_35,1_23,1_55,17_34,1_41,1_54,1_53,17_33,1_183,1_184,1_24,1_33,1_46,1_213,1_211,1_240,1_47,1_52,17_6,1_51,17_14,1_21,1_22,1_40,1_34,1_19,1_224,1_225,1_212,1_218,1_216,1_219,1_220,1_217,1_221,1_214,1_222,1_223,1_227,1_236,1_238,1_239,1_226,1_231,1_232,1_233,1_215,1_228,1_229,1_230,1_234,1_235,1_237,17_48,17_49,17_2,1_59,1_57,17_38,1_56,17_39,1_58,17_40,17_41,1_60,17_3,1_49,17_8,17_9,1_35,17_10,1_63,1_62,17_11,1_50,1_38,17_43,1_43,17_12,17_13,1_67-8NNPn"></script> <div class="articlebody" id="articlebody"> <input id="CurrentDoi" name="CurrentDoi" type="hidden" value="10.5500/wjt.v14.i4.97612" />  <div class="jnavbar" id="full-article-title-container"> <span>Retrospective Study</span> <span style="float:right;padding-right:10px;">Open Access</span> </div>  <div id="dptop"> <div id="dpcopyright"> <a href="http://www.wjgnet.com/bpg/gerinfo/207" target="_blank">Copyright</a> <b>©The Author(s) 2024.</b><span> Published by Baishideng Publishing Group Inc. All rights reserved.</span> </div> <div id="dpjournal"> <span>World J Transplant. </span><span>Dec 18, 2024; </span><span>14(4): 97612</span><br /> <span>Published online Dec 18, 2024. doi: <a href="http://dx.doi.org/10.5500/wjt.v14.i4.97612" target="_self">10.5500/wjt.v14.i4.97612</a></span> </div> <div id="dptitle"> Risk scores for allograft failure: Are they still useful in liver recipients from donation after circulatory death? </div> <div id="dpauthors"> <a href="javascript:void(0);" id="thisauthor684653" class="author-name-link" data-f-name="Mohamed H" data-l-name="Mohamed Chairi" data-name="Mohamed H Mohamed Chairi" target="_self">Mohamed H Mohamed Chairi</a>, <a href="javascript:void(0);" id="thisauthor684654" class="author-name-link" data-f-name="Mónica" data-l-name="Mogollón González" data-name="Mónica Mogollón González" target="_self">Mónica Mogollón González</a>, <a href="javascript:void(0);" id="thisauthor684655" class="author-name-link" data-f-name="Jennifer" data-l-name="Triguero Cabrera" data-name="Jennifer Triguero Cabrera" target="_self">Jennifer Triguero Cabrera</a>, <a href="javascript:void(0);" id="thisauthor684656" class="author-name-link" data-f-name="Inmaculada" data-l-name="Segura Jiménez" data-name="Inmaculada Segura Jiménez" target="_self">Inmaculada Segura Jiménez</a>, <a href="javascript:void(0);" id="thisauthor684657" class="author-name-link" data-f-name="Maria T" data-l-name="Villegas Herrera" data-name="Maria T Villegas Herrera" target="_self">Maria T Villegas Herrera</a>, <a href="javascript:void(0);" id="thisauthor684658" class="author-name-link" data-f-name="Jesús M" data-l-name="Villar del Moral" data-name="Jesús M Villar del Moral" target="_self">Jesús M Villar del Moral</a> </div> <div id="dpaff"> <div><b>Mohamed H Mohamed Chairi, Mónica Mogollón González, Jennifer Triguero Cabrera, Inmaculada Segura Jiménez, Maria T Villegas Herrera, Jesús M Villar del Moral, </b>Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain</div> </div> <div id="dporcid" style="display:;"> <b>ORCID number: </b><span>Mohamed H Mohamed Chairi (<a href='http://orcid.org/0000-0001-8300-7344' target='_blank'>0000-0001-8300-7344</a>).</span> </div> <div id="dpfn"> <div><b>Co-corresponding authors</b>: Mohamed H Mohamed Chairi and Mónica Mogollón González.</div> <div><b>Author contributions</b>: Mohamed Chairi MH and Mogollón González M contributed equally to this study as co-corresponding authors; Mohamed Chairi MH conducted the experiments and analyzed the data; Mogollón González M designed the experimental setup and assisted with data collection and interpretation; Triguero Cabrera J wrote the manuscript and prepared figures and tables for publication; Segura Jiménez I provided critical feedback and revisions to the manuscript before submission; Villegas Herrera MT contributed to literature review and provided insights on previous research relevant to the study; Villar del Moral JM supervised the project and provided overall guidance and direction.</div> <div><b>Institutional review board statement:</b> The study was reviewed and approved by the regional Research Ethics Committee Review Board (Approval No. 576).</div><div><b>Informed consent statement:</b> All study participants or their legal guardian provided informed written consent prior to study enrollment.</div><div><b>Conflict-of-interest statement:</b> No grant has been received for the purpose of the study. No conflict of interests exist in relation to this manuscript.</div><div><b>Data sharing statement:</b> No additional data are available.</div><div><b>Open-Access:</b> This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: <a href="https://creativecommons.org/Licenses/by-nc/4.0/">https://creativecommons.org/Licenses/by-nc/4.0/</a></div><div><b>Corresponding author</b>: Mohamed H Mohamed Chairi, PhD, Doctor, Medical Assistant, Surgeon, Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Fuerzas Armadas Av. No. 2, Granada 18013, Andalusia, Spain. <NewLine /><a href="mailto:yasinmc1994@gmail.com">yasinmc1994@gmail.com</a></div> <div><b>Received:</b> June 3, 2024<br /><b>Revised:</b> July 17, 2024<br /><b>Accepted:</b> August 2, 2024<br /><b>Published online:</b> December 18, 2024<br /><b>Processing time:</b> 108 Days and 16.4 Hours<br /></div> </div> <br /> </div>  <div id="article-abstract-container"> <div class="article-section-title-0"> <span>Abstract</span> </div> <div id="dpabstract"> <div><div class="article-section-title-1">BACKGROUND</div><p>Liver grafts from donation after circulatory death (DCD) are associated with a higher risk of early graft dysfunction, determined by the warm ischemia and cold ischemia times. It is essential to have precise criteria to identify this complication in order to guide therapeutic strategies.</p> <div class="article-section-title-1">AIM</div><p>To validate different graft and recipient survival scores in patients undergoing liver transplantation (LT) with DCD grafts.</p> <div class="article-section-title-1">METHODS</div><p>A retrospective and observational unicentric study was conducted on 65 LT patients with grafts obtained from controlled DCD donors from November 2013 to November 2022. The United Kingdom (UK) risk score, early allograft dysfunction (EAD) Olthoff score, and model for early allograft function (MEAF) score were used to evaluate the risk of graft and recipient survival post-transplant. For survival analysis purposes, we used the Kaplan-Meier method, and the differences between subgroups were compared using the log-rank (Mantel-Cox) test.</p> <div class="article-section-title-1">RESULTS</div><p>Sixty-five patients were included in the study. The UK risk score did not demonstrate predictive capacity for recipient or graft survival. However, in donors aged over 70 years old (18.4%), it significantly predicted graft survival (<i>P</i> < 0.05). According to Kaplan-Meier survival curves, graft survival rates at 6 months, 2 years, and 5 years in the futility group dramatically decreased to 50% compared to the other groups (log-rank 8.806, <i>P</i> < 0.05). The EAD Olthoff and MEAF scores did not demonstrate predictive capacity for recipient or graft survival. Based on Kaplan-Meier survival curves, patients with a MEAF score ≥ 7 had a lower graft survival rate at 6 months, 2 years, and 5 years compared to patients with a lower MEAF score (log-rank 4.667, <i>P</i> < 0.05).</p> <div class="article-section-title-1">CONCLUSION</div><p>In our series, both UK DCD risk score and MEAF score showed predictive capability for graft survival.</p> </div> <div class="article-abstract-item" style="display:;"> <b>Key Words: </b><span><a href='https://www.f6publishing.com/ArticlesByKeywords?type=2&pageNumber=1&keyword=Liver+transplantation' target='blank'>Liver transplantation</a>; <a href='https://www.f6publishing.com/ArticlesByKeywords?type=2&pageNumber=1&keyword=Donation+after+circulatory+death' target='blank'>Donation after circulatory death</a>; <a href='https://www.f6publishing.com/ArticlesByKeywords?type=2&pageNumber=1&keyword=Early+allograft+dysfunction' target='blank'>Early allograft dysfunction</a>; <a href='https://www.f6publishing.com/ArticlesByKeywords?type=2&pageNumber=1&keyword=Risk+scores' target='blank'>Risk scores</a>; <a href='https://www.f6publishing.com/ArticlesByKeywords?type=2&pageNumber=1&keyword=Graft+survival.' target='blank'>Graft survival.</a></span> </div> <br /> <div class="article-abstract-item"> <span><p><b>Core Tip:</b> Controlled donation after circulatory death (DCD) grafts are increasingly being used in liver transplantation, and in some countries, more than one‐third of the deceased donor liver transplants are performed with DCD grafts. Nonetheless, DCD grafts are not risk-free. Despite the increased complexity in predicting outcomes for liver transplant recipients from DCD, risk scores for allograft failure remain a valuable tool in assisting clinicians in identifying patients at higher risk for adverse outcomes and guiding decision-making in post-transplant care.</p></span> </div> <div id="dpcitation" class="article-abstract-item rs_skip"> <hr /> <ul> <li> <b>Citation: </b>Mohamed Chairi MH, Mogollón González M, Triguero Cabrera J, Segura Jiménez I, Villegas Herrera MT, Villar del Moral JM. Risk scores for allograft failure: Are they still useful in liver recipients from donation after circulatory death? <i>World J Transplant</i> 2024; 14(4): 97612 </li> <li> <b>URL: </b><a href="https://www.wjgnet.com/2220-3230/full/v14/i4/97612.htm" target="_self">https://www.wjgnet.com/2220-3230/full/v14/i4/97612.htm</a> </li> <li> <b>DOI: </b><a href="https://dx.doi.org/10.5500/wjt.v14.i4.97612" target="_self">https://dx.doi.org/10.5500/wjt.v14.i4.97612</a> </li> </ul> <hr/> </div> </div> </div>  <div id="article-main-container"> <div> <div id="sec11"><div id="sec11title" class="article-section-title-0">INTRODUCTION</div><p class="article-section-content" id="p11">Liver transplantation (LT) represents the treatment of choice in the end stage of certain liver diseases when all other therapeutic alternatives have been exhausted[<a class="refcontent" href="#B1" data-jats-ref-type="bibr" data-jats-rid="B1">1</a>]. The incorporation of donation after circulatory death (DCD) has enabled an increase in organ availability to meet the growing demand, leading to an increase in the number of transplants. Five categories of DCD have been defined based on the context of the death. In uncontrolled DCD categories I and II, circulatory death occurs suddenly and unexpectedly without medical presence or control and without success after cardiopulmonary resuscitation maneuvers. In controlled DCD (cDCD) categories III, IV, and V, circulatory death occurs in a hospital setting and under medical control[<a class="refcontent" href="#B2" data-jats-ref-type="bibr" data-jats-rid="B2">2</a>]. Currently, cDCD is steadily and gradually expanding. According to donation and transplant activity data in Spain for 2022, DCD accounted for a 38% increase compared to the previous year, representing 42% of the current total donations, with over 92% of cases being cDCD[<a class="refcontent" href="#B3" data-jats-ref-type="bibr" data-jats-rid="B3">3</a>,<a class="refcontent" href="#B4" data-jats-ref-type="bibr" data-jats-rid="B4">4</a>].</p><p class="article-section-content" id="p12">Grafts from cDCD donors are associated with a higher risk of early graft dysfunction, mainly related to the length of warm ischemia time and cold ischemia time (CIT). Early allograft dysfunction (EAD) dramatically influences graft and patient outcomes. Several studies have shown that the most favorable outcomes in LT using grafts from cDCD donors are associated with young donors, short functional warm ischemia times (FWIT; ≤ 12 min), and limited CIT (< 6 h). Precise criteria are essential to identify complications and guiding therapeutic strategies[<a class="refcontent" href="#B5" data-jats-ref-type="bibr" data-jats-rid="B5">5</a>].</p><p class="article-section-content" id="p13">The aim of the following study was to validate the currently available LT outcome scores for both graft and recipient survival in cDCD.</p></div><div id="sec12"><div id="sec12title" class="article-section-title-0">MATERIALS AND METHODS</div><div id="sec21"><div id="sec21title" class="article-section-title-1">Study design</div><p class="article-section-content" id="p21">A retrospective and observational unicentric study was conducted on LT patients with grafts obtained from cDCD donors from November 2013 to November 2022. The study has been reviewed and approved by the regional Research Ethics Committee. All study participants or their legal guardian provided informed written consent prior to study enrollment. Exclusion criteria were: super-rapid recovery technique, insufficient data, and retrieval procedure performed by other transplant teams. Within the study group, three parameters were defined to build a high-risk cohort: Donors aged ≥ 70, CIT ≥ 6 h, and FWIT ≥ 12 min. Both graft and recipient survival were evaluated.</p><p class="article-section-content" id="p22">We analyzed the performance in our series of the United Kingdom (UK) DCD risk score, Olthoff definition and model for early allograft function (MEAF) score. Scores were calculated as described in their respective original publications[<a class="refcontent" href="#B1" data-jats-ref-type="bibr" data-jats-rid="B1">1</a>,<a class="refcontent" href="#B6" data-jats-ref-type="bibr" data-jats-rid="B6">6</a>,<a class="refcontent" href="#B7" data-jats-ref-type="bibr" data-jats-rid="B7">7</a>]. UK DCD risk score stratifies cDCD liver recipients according to seven variables and aims to predict 1-year graft survival. Donor age > 60 years, cold ischemia > 6 h, and recipient lab model for end-stage liver disease score > 25 were assigned 2 points each; donor body mass index > 25, functional warm ischemia > 20-30 min, and recipient age > 60 years 3 points; functional warm ischemia > 30 min 6 point and retransplantation 9 points. Scores of 0-5 are ‘‘low risk” (1-year graft survival > 95%), 6–10 ‘‘high-risk” (1-year graft survival > 85%), and > 10 ‘‘futile” (1-year graft survival < 40%)[<a class="refcontent" href="#B6" data-jats-ref-type="bibr" data-jats-rid="B6">6</a>]. Olthoff defined the presence or absence of EAD within the first 7 post-operative days, based on levels of aminotransferases, bilirubin and international normalized ratio[<a class="refcontent" href="#B7" data-jats-ref-type="bibr" data-jats-rid="B7">7</a>]. The MEAF score developed by Pareja <i>et al</i>[<a class="refcontent" href="#B1" data-jats-ref-type="bibr" data-jats-rid="B1">1</a>] consists of a nonlinear regression model based on the peak values of three post-operative laboratory parameters: The maximum of alanine aminotransferase and international normalized ratio within the first 3 days and the bilirubin on the third post-operative day. In this case, we considered a score of 7 to mark the high-risk group based on our previous experience[<a class="refcontent" href="#B8" data-jats-ref-type="bibr" data-jats-rid="B8">8</a>].</p></div><div id="sec22"><div id="sec22title" class="article-section-title-1">Statistical analyses</div><p class="article-section-content" id="p21">Data were expressed as median and interquartile range for continuous variables and as percentages for categorical variables. The Kolmogorov-Smirnov test was used to assess the normality of each continuous variable. Univariate analysis was performed using <i>χ</i><sup>2</sup> or Fisher tests for categorical data and Mann-Whitney <i>U</i> or Kruskall-Wallis tests for continuous data. For survival analysis, we used the Kaplan-Meier method, and the differences between subgroups were compared using the log-rank (Mantel-Cox) test. IBM SPSS Statistics 20.0 (IBM Corp., Armonk, NY, United States) was used for statistical analysis. A <i>P</i> < 0.05 was considered statistically significant.</p></div></div><div id="sec13"><div id="sec13title" class="article-section-title-0">RESULTS</div><p class="article-section-content" id="p11">A total of 348 LTs were conducted in this period of time, 72 from cDCD. Seven patients were excluded: 2 were super-rapid recovery technique, 1 had insufficient data, and 4 were performed by other transplant teams. Sixty-five patients fulfilled inclusion criteria. Forty-three (66.1%) were transplanted for alcohol-associated cirrhosis [of which 18 (27.7%) had subsidiary hepatocarcinoma], 11 (16.9%) for cirrhosis due to hepatitis C virus [6 (9.2%) with hepatocarcinoma], 4 (6.1%) for cirrhosis due to hepatitis B virus [3 (4.6%) with hepatocarcinoma], 6 (9.2%) for primary biliary cholangitis and 1 (1.5%) for cryptogenetic cirrhosis.</p><p class="article-section-content" id="p12">In the donor group, 60% were men. The main cause of death (58.4%) was stroke. Among the recipients, 81.5% were male, with a median age of 57 (52-63) years.</p><p class="article-section-content" id="p13">The median operative time was 340 (325-420) min. The median number of transfused red blood cell packs was 5 (2-7). Regarding vessel reconstruction, temporary portocaval shunt was performed in almost half (46.8%) of the transplants; in 90.7% of cases, a single end-to-end vascular reconstruction was performed; in the remaining 9.3% of cases, multiple reconstructions were required due to vascular anomalies present in the donor, the recipient, or both.</p><p class="article-section-content" id="p14">Functional WIT was > 12 min in 46 donors (63.1%), CIT was ≥ 6 h in 13 patients (20%), and 12 donors were older than 70 (18.5%). According to UK DCD risk score, four patients (6.2%) were classified in the “futile” group, and 23 patients (35.4%) were categorized as the “high risk” group. Twelve patients (20%) developed EAD according to Olthoff criteria, and seven (11.6%) scored ≥ 7 points (indicating severe dysfunction) according to the MEAF score.</p><p class="article-section-content" id="p15">The patients were monitored after surgery with a median clinical follow-up of 13 (5.2-42.7) months. At the time of analysis, 15 patients (23.1%) had died. The overall survival rate was 89.1% at 1 year, 76.2% at 3 years, and 74% at 5 years. In contrast, the graft survival rates at 1 year, 3 years and 5 years were 84.2%, 69.4%, and 67.9%, respectively.</p><p class="article-section-content" id="p16">Regarding the global predictive capacity of UK DCD risk score for survival, we did not observe a significant correlation between group risk and patient (<i>P</i> = 0.173) or graft survival (<i>P</i> = 0.162). However, in donors aged over 70 years (18.4%), the score significantly predicted graft survival (<i>P</i> < 0.05) and exhibited a trend towards significance in recipient survival <InlineParagraph>(<i>P</i> = 0.088; Table <a class="refcontent" href="#T1" data-jats-ref-type="table" data-jats-rid="T1">1</a>).</InlineParagraph> Based on Kaplan-Meier survival curves, 6-month, 2-year and 5-year graft survival rates were 97.3%, 95.5% and 95%, respectively, in the low-risk group, while those in the high-risk group were 95.5%, 89.6% and 89.5%, respectively. In the futile group, survival rates drastically decreased to 50% (log-rank 8.806, <i>P</i> < 0.05; Figure <a class="refcontent" href="#F1" data-jats-ref-type="fig" data-jats-rid="F1">1A</a>).</p><div class="article-item-container article-item-fig" id="F1"> <div class="article-item-image-container"> <a href="http://www.wjgnet.com/2220-3230/full/v14/i4/97612-g001.htm" target="_blank"> <picture> <source srcset="https://f6publishing.blob.core.windows.net/d7fe4fa9-42ba-46c7-a8da-ea1549a02684/97612-g001.webp" alt="Figure 1" loading="lazy" class="graphic" type="image/webp" /> <img src="https://f6publishing.blob.core.windows.net/d7fe4fa9-42ba-46c7-a8da-ea1549a02684/97612-g001.png" class="graphic" alt="Figure 1" loading="lazy" border="0" title="Figure 1" /> </picture> </a> <div class="image-btn-container"> <a href="http://www.wjgnet.com/2220-3230/full/v14/i4/97612-g001.htm" class="image-btn" target="_blank">Open in New Tab</a>   <a href="https://f6publishing.blob.core.windows.net/d7fe4fa9-42ba-46c7-a8da-ea1549a02684/97612-g001.png" class="image-btn" target="_blank">Full Size Figure</a>   <a href="https://www.f6publishing.com/forms/main/downloadfile.aspx?download=true&FilePath=81F2CBDAA240332F1F834EB8483E90BD01BFB17950B0169FF0346E355604B8125126066BB01823BAACC42B115F56066208A05B987DF109E8" class="image-btn" target="_blank">Download Figure</a> </div> </div> <div> <b>Figure 1 <b>Kaplan-Meier survival graphs depicting graft survival.</b></b> <span> A: United Kingdom (UK) risk score subgroup; B: Model for early allograft function (MEAF) score subgroup. </span> </div> </div> <figure id="T1" class="figure_table"> <figcaption class="Caption"> <div class="caption_content"> <a href="http://www.wjgnet.com/2220-3230/full/v14/i4/97612-T1.htm" target="_blank"><span class="caption_number">Table 1</span></a> Correlation of overall and graft survival according to the United Kingdom risk score, subdivided by high-risk subgroups. </div> </figcaption> <div class="table-container" style="width:666px;"> <table class="table-container" border="1"><thead><tr><td rowspan="2"><b>Survival</b></td><td colspan="3"><b>Donors aged ≥ 70 years</b><hr /></td><td colspan="4"><b>Cold ischemia time ≥ 6 h</b><hr /></td><td colspan="4"><b>Functional warm ischemia time ≥ 12 min</b><hr /></td></tr><tr><td><b>Low risk, <i>n</i> = 5</b><hr /></td><td><b>High risk, <i>n</i> = 7</b><hr /></td><td><b><i>P</i> value</b><hr /></td><td><b>Low risk, <i>n</i> = 6</b><hr /></td><td><b>High risk, <i>n</i> = 4</b><hr /></td><td><b>Futile, <i>n</i> = 3</b><hr /></td><td><b><i>P</i> value</b><hr /></td><td><b>Low risk, <i>n</i> = 24</b><hr /></td><td><b>High risk, <i>n</i> = 18</b><hr /></td><td><b>Futile, <i>n</i> = 4</b><hr /></td><td><b><i>P</i> value</b><hr /></td></tr></thead><tbody><tr><td>Graft survival in days</td><td>420 (306-1636)</td><td>236 (1-395)</td><td>0.048<sup><a class="refcontent" href="#T1FN1" data-jats-ref-type="table-fn" data-jats-rid="T1FN1">1</a></sup></td><td>987 (11-1657)</td><td>592 (47-1480)</td><td>2 (1-3)</td><td>0.330<sup><a class="refcontent" href="#T1FN2" data-jats-ref-type="table-fn" data-jats-rid="T1FN2">2</a></sup></td><td>505 (179-1469)</td><td>357 (1.2-1134)</td><td>218 (100-685)</td><td>0.340<sup><a class="refcontent" href="#T1FN2" data-jats-ref-type="table-fn" data-jats-rid="T1FN2">2</a></sup></td></tr><tr><td>Overall survival in months</td><td>13 (9-53)</td><td>7 (1-12)</td><td>0.088<sup><a class="refcontent" href="#T1FN1" data-jats-ref-type="table-fn" data-jats-rid="T1FN1">1</a></sup></td><td>32 (3.7-53)</td><td>19 (1.5-47.7)</td><td>8 (6-9)</td><td>0.847<sup><a class="refcontent" href="#T1FN2" data-jats-ref-type="table-fn" data-jats-rid="T1FN2">2</a></sup></td><td>16 (5-48)</td><td>15 (8-36)</td><td>7 (2.7-22)</td><td>0.678<sup><a class="refcontent" href="#T1FN2" data-jats-ref-type="table-fn" data-jats-rid="T1FN2">2</a></sup></td></tr></tbody></table> </div> <div class="table_footer"> <div> <div id=''>Data are median (interquartile range).</div><div id='T1FN1'><sup>1</sup><i>U</i>-Mann Whitney test.</div><div id='T1FN2'><sup>2</sup>Kruskall-Wallis test.</div> </div> </div> </figure> <p class="article-section-content" id="p19">The EAD Olthoff and MEAF scores did not demonstrate predictive capacity for recipient or graft survival, either globally or in any risk subgroup (Tables <a class="refcontent" href="#T2" data-jats-ref-type="table" data-jats-rid="T2">2</a> and <a class="refcontent" href="#T3" data-jats-ref-type="table" data-jats-rid="T3">3</a>). However, focusing on survival analysis among subgroups, patients with a MEAF score ≥ 7 displayed poorer 6-month (98.2% <i>vs</i> 71.4%), 2-year (92% <i>vs</i> 71%) and 5-year (92% <i>vs</i> 0%) graft survival rate than patients with a lower MEAF score (log-rank 4.667, <i>P</i> < 0.05; Figure <a class="refcontent" href="#F1" data-jats-ref-type="fig" data-jats-rid="F1">1B</a>).</p><figure id="T2" class="figure_table"> <figcaption class="Caption"> <div class="caption_content"> <a href="http://www.wjgnet.com/2220-3230/full/v14/i4/97612-T2.htm" target="_blank"><span class="caption_number">Table 2</span></a> Correlation of overall and graft survival according to the early allograft dysfunction Olthoff score, subdivided by high-risk subgroups. </div> </figcaption> <div class="table-container" style="width:666px;"> <table class="table-container" border="1"><thead><tr><td rowspan="2"><b>Survival</b></td><td colspan="3"><b>Donors aged ≥ 70 years</b><hr /></td><td colspan="3"><b>Cold ischemia time ≥ 6 h</b><hr /></td><td colspan="3"><b>Functional warm ischemia time ≥ 12 min</b><hr /></td></tr><tr><td><b>Meet, <i>n</i> = 2</b><hr /></td><td><b>Does not meet, <i>n</i> = 10</b><hr /></td><td><b><i>P</i> value</b><hr /></td><td><b>Meet, <i>n</i> = 7</b><hr /></td><td><b>Does not meet, <i>n</i> = 6</b><hr /></td><td><b><i>P</i> value</b><hr /></td><td><b>Meet, <i>n</i> = 19</b><hr /></td><td><b>Does not meet, <i>n</i> = 27</b><hr /></td><td><b><i>P</i> value</b><hr /></td></tr></thead><tbody><tr><td>Graft survival in days</td><td>210 (1-220)</td><td>319 (265-569)</td><td>0.582<sup><a class="refcontent" href="#T2FN1" data-jats-ref-type="table-fn" data-jats-rid="T2FN1">1</a></sup></td><td>505 (2-1641)</td><td>998 (100-1556)</td><td>0.530<sup><a class="refcontent" href="#T2FN2" data-jats-ref-type="table-fn" data-jats-rid="T2FN2">2</a></sup></td><td>400 (123-907)</td><td>505 (107-1641)</td><td>0.443<sup><a class="refcontent" href="#T2FN2" data-jats-ref-type="table-fn" data-jats-rid="T2FN2">2</a></sup></td></tr><tr><td>Overall survival in months</td><td>6.5 (1-7)</td><td>10 (8-18)</td><td>0.482<sup><a class="refcontent" href="#T2FN1" data-jats-ref-type="table-fn" data-jats-rid="T2FN1">1</a></sup></td><td>16 (5-53)</td><td>32 (3-50)</td><td>0.965<sup><a class="refcontent" href="#T2FN2" data-jats-ref-type="table-fn" data-jats-rid="T2FN2">2</a></sup></td><td>12.5 (3.5-29)</td><td>16 (5-53)</td><td>0.854<sup><a class="refcontent" href="#T2FN2" data-jats-ref-type="table-fn" data-jats-rid="T2FN2">2</a></sup></td></tr></tbody></table> </div> <div class="table_footer"> <div> <div id=''>Data are median (interquartile range).</div><div id='T2FN1'><sup>1</sup><i>U</i>-Mann Whitney test.</div><div id='T2FN2'><sup>2</sup>Kruskall-Wallis test.</div> </div> </div> </figure> <figure id="T3" class="figure_table"> <figcaption class="Caption"> <div class="caption_content"> <a href="http://www.wjgnet.com/2220-3230/full/v14/i4/97612-T3.htm" target="_blank"><span class="caption_number">Table 3</span></a> Correlation of overall and graft survival according to model for early allograft function score, subdivided by high-risk subgroups. </div> </figcaption> <div class="table-container" style="width:666px;"> <table class="table-container" border="1"><thead><tr><td rowspan="2"><b>Survival</b></td><td colspan="3"><b>Donors aged ≥ 70 years</b><hr /></td><td colspan="3"><b>Cold ischemia time ≥ 6 h</b><hr /></td><td colspan="3"><b>Functional warm ischemia time ≥ 12 min</b><hr /></td></tr><tr><td><b>MEAF < 7, <i>n</i> = 10</b><hr /></td><td><b>MEAF ≥ 7, <i>n</i> = 2</b><hr /></td><td><b><i>P</i> value</b><hr /></td><td><b>MEAF < 7, <i>n</i> = 8</b><hr /></td><td><b>MEAF ≥ 7, <i>n</i> = 5</b><hr /></td><td><b><i>P</i> value</b><hr /></td><td><b>MEAF < 7, <i>n</i> = 38</b><hr /></td><td><b>MEAF ≥ 7, <i>n</i> = 8</b><hr /></td><td><b><i>P</i> value</b><hr /></td></tr></thead><tbody><tr><td>Graft survival in days</td><td>420 (410-430)</td><td>315 (219-563)</td><td>0.627<sup><a class="refcontent" href="#T3FN1" data-jats-ref-type="table-fn" data-jats-rid="T3FN1">1</a></sup></td><td>751 (57-1642)</td><td>357 (2-1280)</td><td>0.461<sup><a class="refcontent" href="#T3FN2" data-jats-ref-type="table-fn" data-jats-rid="T3FN2">2</a></sup></td><td>420 (2-1091)</td><td>409 (153-1279)</td><td>0.666<sup><a class="refcontent" href="#T3FN2" data-jats-ref-type="table-fn" data-jats-rid="T3FN2">2</a></sup></td></tr><tr><td>Overall survival in months</td><td>13 (2-18)</td><td>10 (6.5-18)</td><td>0.727<sup><a class="refcontent" href="#T3FN1" data-jats-ref-type="table-fn" data-jats-rid="T3FN1">1</a></sup></td><td>24 (1.5-53)</td><td>15.5 (5.7-41.7)</td><td>0.808<sup><a class="refcontent" href="#T3FN2" data-jats-ref-type="table-fn" data-jats-rid="T3FN2">2</a></sup></td><td>13 (4-35)</td><td>13 (4.5-41)</td><td>0.432<sup><a class="refcontent" href="#T3FN2" data-jats-ref-type="table-fn" data-jats-rid="T3FN2">2</a></sup></td></tr></tbody></table> </div> <div class="table_footer"> <div> <div id=''>Data are median (interquartile range).</div><div id='T3FN1'><sup>1</sup><i>U</i>-Mann Whitney test.</div><div id='T3FN2'><sup>2</sup>Kruskall-Wallis test.</div><div id=''>MEAF: Model for early allograft function.</div> </div> </div> </figure> </div><div id="sec14"><div id="sec14title" class="article-section-title-0">DISCUSSION</div><p class="article-section-content" id="p11">LT risk scoring systems offer valuable insights for predicting outcomes, a key point in the era of more widespread use of extended criteria donor livers and potentially reduced graft quality. Nevertheless, there is no consensus on the clinical criteria to define EAD and no one score is considered the gold standard. According to our results, both MEAF and UK DCD risk score have shown an association with graft survival prediction, though not with patient survival. In our sample, the threshold defined by Olthoff score did not exhibit an association with either graft survival or overall survival.</p><p class="article-section-content" id="p12">UK DCD risk score was designed to predict risk and futility in the context of cDCD LT[<a class="refcontent" href="#B6" data-jats-ref-type="bibr" data-jats-rid="B6">6</a>]; however, its application requires caution. Several variables included in the score are not directly related to the donor and graft itself. For instance, assigning a score of 9 to the retransplantation item implies considering nearly all retransplantations as futile. Consequently, some critical risk factors may be downplayed or omitted entirely in the final risk stratification score.</p><p class="article-section-content" id="p13">Pareja <i>et al</i>[<a class="refcontent" href="#B1" data-jats-ref-type="bibr" data-jats-rid="B1">1</a>] introduced the MEAF score to assess the severity of EAD. This model demonstrates a significant association with both patient and graft outcomes (in our data, only with graft outcomes), enabling survival estimation for a concrete recipient. Despite MEAF utilizing a continuous concept, it does not capture the trend or rate of change in variables. Cases with gradually increasing laboratory test values post-LT differ from cases with a rapid decline, even if they initially exhibited similar results.</p><p class="article-section-content" id="p14">This study presents several limitations that must be considered when interpreting the results. Firstly, it is important to highlight that the study design is non-randomized and relies on historical data, which may introduce selection bias and confounding variables that could impact the validity of the findings. Moreover, the median duration of follow-up is relatively short, which limits the ability to assess long-term outcomes and the durability of the risk scores for predicting allograft failure in liver transplant recipients. Additionally, the sample size of patients included in the study is relatively small, which may limit the generalizability of the results and the statistical power to detect significant associations. Furthermore, while the study focuses on the utility of these three risk scores for predicting allograft failure, UK DCD risk score, Olthoff definition and MEAF score, it would be valuable to explore the potential use of other risk assessment tools or scores in this population to improve the accuracy and reliability of predicting graft survival. By incorporating alternative risk scores or predictive models, researchers may be able to enhance the predictive capacity and clinical utility of risk assessment in liver transplant recipients receiving livers from DCD.</p></div><div id="sec15"><div id="sec15title" class="article-section-title-0">CONCLUSION</div><p class="article-section-content" id="p11">In our series, both UK DCD risk score and MEAF score showed predictive capability for graft survival. They can help in the election of the best matching donor/recipient, and they can become a useful tool in informed decision-making. Larger sample sizes, a long duration of follow-up, prospective studies, and the application of additional prognostic scores are necessary for more robust results.</p></div><div id="sec16"><div id="sec16title" class="article-section-title-0">ACKNOWLEDGEMENTS</div><p class="article-section-content" id="p11">The authors would like to extend their heartfelt gratitude to the dedicated team of liver transplantation specialists at Virgen de las Nieves University Hospital for their tireless dedication and exceptional patient care. Their unwavering commitment to excellence in liver transplantation has resulted in countless lives being saved and transformed. We thank them for all for their hard work, dedication, and commitment to improving the lives of others through liver trans<Hypen />plantation. Their contributions are truly invaluable, and we are each honored to work alongside such a talented and dedicated team.</p></div> </div> <div class="article-section-title-0" style="display:block"> <span>Footnotes</span> </div> <div style="display:block;" class="article-section-content"> <p><bold>Provenance and peer review:</bold> Invited article; Externally peer reviewed.</p><p><bold>Peer-review model:</bold> Single blind</p><p><bold>Corresponding Author's Membership in Professional Societies:</bold> Spanish Association of Surgeons, 15674; Andalusian Society of Organ and Tissue Transplantation, 3452; Spanish Society of Transplantation, 8432; European Society of Organ Transplantation.</p><p><bold>Specialty type:</bold> Transplantation</p><p><bold>Country of origin:</bold> Spain</p><p><bold>Peer-review report’s classification</bold></p><p><bold>Scientific Quality:</bold> Grade C</p><p><bold>Novelty:</bold> Grade B</p><p><bold>Creativity or Innovation:</bold> Grade 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