Liver transplantation from donors following medical assistance in dying: a scoping review and retrospective cohort study.

Abstract

Background: Liver transplantation from donors following medical assistance in dying (MAiD) is a novel practice with emerging Canadian outcomes data. We sought to compare donor and recipient outcomes after liver transplantation following donor MAiD, circulatory death (DCD), or brain death (DBD).

Methods: We conducted a scoping review and a single-centre retrospective cohort study.

Results: The 5 retrospective studies identified found comparable short-term liver graft and patient survival between MAiD, DCD, and DBD liver recipients, with no differences in vascular complications or primary nonfunction. One study noted higher biliary complications among MAiD liver recipients. Our single-centre retrospective cohort reporting included 177 liver transplant recipients between 2018 and 2024 (19 MAiD, 14 DCD, and 144 DBD donors). Among donors, MAiD (mean age 59 yr) and DBD (mean age 57 yr) donors were older than DCD donors (mean age 37 yr; p < 0.001) and had lower median body mass index than other donors (MAiD 20, DCD 22, DBD 26; p < 0.001). Cold ischemia times were longest for DBD grafts (6.6 h v. 6.2 h DCD and 5.8 h MAiD; p = 0.02), with no other intraoperative differences. Rates of mortality within 90 days (p = 0.7), complications (Clavien-Dindo grade ≥ 3; p = 0.4), and retransplant (p = 0.6) were comparable across groups. Biliary strictures affected 42% MAiD, 35% DCD, and 13% DBD livers (p = 0.005), mostly extrahepatic and anastomotic strictures. Kaplan-Meier analysis found no significant difference in graft survival between donor groups (p = 0.7), Cox regression identified portal vein thrombosis (hazard ratio [HR] 23.98, 95% confidence interval [CI] 2.41 to 238.15), hepatic artery thrombosis (HR 8.14, 95% CI 1.72 to 38.54), and biliary complications (HR 11.93; 95% CI 2.31 to 61.76) as independent predictors of graft loss.

Conclusion: Liver transplantation from donors who underwent MAiD was not associated with higher graft loss or mortality than in those who underwent DCD or DBD. Its continued use is safe, and larger multicentre studies are warranted for validation.