Standard and Extended Criteria Donors
Livers from deceased donors fall into two categories: standard criteria donor (SCD) livers and extended criteria donor (ECD) livers.
A standard criteria donor (SCD) liver comes from a deceased donor who is declared brain dead. Brain death is defined when someone is maintained on life support - including a respirator that breathes for him or her - and has a beating heart. This can happen after a severe traumatic brain injury, stroke or other injury to the brain. Brain death means that there is the irreversible loss of function of the brain. A diagnosis of brain death can be made on a careful neurological examination or by demonstrating loss of blood flow to the brain. A flatline EEG can also be used to confirm brain death (an EEG, or electroencephalogram, records and measures the brain's electrical activity). Once brain death has been declared, the donor is legally dead.
An extended criteria donor (ECD) liver comes from a deceased donor who has certain risk factors. The severe shortage of organs, and the growing wait for livers, has led to more widespread use of livers from donors not commonly used in the past. Extended liver criteria vary among transplant programs. At the BIDMC Transplant Institute, extended criteria donors have some or all of the following risk factors:
- The deceased donor is over age 60
- The donor tests positive for Hepatitis C virus
- The donor liver has been harvested and cooled in a special preservation solution for more than 12 hours
- The donor has an accumulation of fat in the liver cells
- The organ is a partial or split-donor liver
- The liver function tests in the donor are abnormal related to the injury causing the donor's death
- The organ comes from outside the New England Organ Bank Region 1
- The donor is on medications to support blood pressure
- The donor stayed in the Intensive Care Unit for more than five days
We tell patients in advance that ECD livers may not be perfect. There is an increased risk of early and late loss of the liver. However, the data shows that your survival is better with an ECD liver than if you stay on the waiting list, depending on your MELD score and the number of donor risk factors. So for some patients, an ECD liver is a good option.
If an ECD liver becomes available and is a match for you, your physicians and surgeons will discuss with you specific aspects of the donor and the liver to help you make a decision about whether or not this is a good liver for you.
Still Other Extended Criteria Donors
Another type of non-standard donor liver is from a non heart-beating donor, also known as Donation after Cardiac Death (DCD). These are donors with severe brain injury with no hope for meaningful recovery and who do not meet the criteria for brain death. The family in consultation with the patient's physician may decide to withdraw life support. After the patient's heart stops and he or she is declared dead, the patient is taken to the operating room and the organs are removed.
Again, criteria for DCD donors vary among transplant programs. At the BIDMC Transplant Institute, our DCD donor and donor organ criteria include, but are not limited to:
- The standard organ donor criteria for acceptability also apply to DCD livers
- The deceased donor is less than age 55
- The time from withdrawal of support until the heart stops and the donor is declared dead must be less than 30 minutes
- The donor liver must be able to be transplanted into the recipient within eight hours of removal from the donor
- The donor liver must not have a large amount of fat in the liver cells
- The liver must look healthy after it is flushed with preservation solution before it is removed from the donor
- The donor liver is free of liver disease, confirmed by biopsy
Again, because of the shortage of organs, and the growing numbers of patients waiting for transplantation, there are still other extended criteria donors. Your transplant team may propose you accept donor organs
- With a history of Hepatitis C virus infection if you have liver disease due to Hepatitis C
- With a history of exposure to Hepatitis B as determined by blood tests or
- From deceased individuals with high-risk lifestyles such as intravenous drug users and prostitutes
If one of these ECD livers is offered to you, your transplant team will discuss whether this is a good option for you and what the risks and benefits would be. Liver allocation and criteria for deceased donors is a complex process but we are here to offer advice and support, and to help you decide what is the best treatment choice for you. We firmly believe in being honest and transparent with you about all aspects of your liver transplant.
Leaders in ECD Livers
The Transplant Institute at Beth Israel Deaconess Medical Center is one of the nation's leaders in use of extended criteria donor livers, including donors after cardiac death, with excellent outcomes. Our team is available 24 hours a day, seven days a week, 365 days a year to perform the transplantation surgery to ensure the best opportunity for a successful transplant outcome. Our program emphasizes short preservation times to maximize the function of the liver in the recipient.
For More Information
The transplant team will explain the different types of deceased donors to you during your pre-transplant clinic visits. You will decide which option you wish to pursue by signing a consent form. Ask your transplant team for more information if you have any questions about the different types of deceased donors and the allocation process.