Expanding Donor Pools: Outcomes of Liver Transplantation Using Grafts from Medical Assistance in Dying Donors in Canada

Highlight

– Liver grafts from donors following medical assistance in dying (MAiD) show comparable patient and graft survival to standard donation after circulatory death (DCD-III) liver grafts.
– The use of MAiD donors contributed to a 21.8% increase in the DCD liver transplantation activity in Canada from 2016 to 2023.
– Early allograft dysfunction rates were lower in MAiD donor grafts, although hospital length of stay was longer.
– Biliary complications and major postoperative events did not differ significantly between MAiD and standard DCD donors.

Study Background

Liver transplantation (LT) remains a critical treatment for end-stage liver disease but is limited by shortages of viable donor organs. Donation after circulatory death (DCD) has expanded the donor pool, but outcomes can vary by the nature of the circulatory death subtype. In Canada, the legalization of medical assistance in dying (MAiD) in 2016 introduced a novel source of organ donors—individuals undergoing circulatory death following MAiD (designated DCD type-V). Given the unique circumstances and ethical considerations surrounding MAiD, and variations in international legislation, limited data exist on the clinical outcomes following liver transplantation using grafts from these donors. Addressing both clinical efficacy and safety, the Canadian multicenter study examines how MAiD donor grafts compare with traditional DCD-III donor grafts regarding transplant outcomes and complications.

Study Design

This retrospective multicenter cohort study spanned all Canadian provinces, reviewing liver transplant recipients from 2016 to 2023. The study population included all patients receiving liver grafts procured from two donor types: DCD type-V (post-MAiD circulatory death) and DCD type-III (controlled withdrawal of life-sustaining therapy). Key inclusion criteria were those undergoing LT with grafts from these donor categories, starting from MAiD legalization. Primary endpoints focused on recipient and graft survival rates at 1, 3, and 5 years post-transplant. Secondary endpoints encompassed early allograft dysfunction (EAD), length of hospital stay (LOS), postoperative complications, and biliary complications. The study leveraged logistic regression and multivariable Cox proportional hazards models to evaluate graft loss risk between donor types.

Key Findings

A total of 313 patients underwent liver transplantation using DCD grafts: 56 (17.9%) from DCD-V donors and 257 (82.1%) from DCD-III donors. Notably, the DCD-V donors were significantly older (median 56 vs. 38 years, p < 0.0001), but warm ischemic times were similar (median 20 vs. 23 minutes, p=0.190), reflecting equivalent organ ischemic conditions despite donor differences.

Patient and Graft Survival

Recipient survival following DCD-V transplantation was 89.3%, 85.7%, and 85.7% at 1-, 3-, and 5-year time points, respectively. Graft survival for the same group was 82.1%, 78.6%, and 78.6%. These outcomes were comparable to those observed with DCD-III donors, with no statistically significant differences in survival. Risk assessment using odds ratios (OR 1.35; 95% CI: 0.39–4.68) and multivariable Cox regression analysis (hazard ratio 1.58; 95% CI: 0.59–4.27) showed no significant association between DCD-V donor usage and graft loss, confirming the safety and efficacy of MAiD donor grafts.

Secondary Outcomes

Interestingly, early allograft dysfunction was less frequent in the DCD-V group (42.9%) compared to DCD-III (57.5%), reaching statistical significance (p=0.047). However, recipients of MAiD donor grafts had a longer hospital length of stay (median 21.5 vs. 15 days, p=0.011), a factor warranting further exploration which may relate to donor age or perioperative management differences. Rates of postoperative complications, including biliary complications, did not differ significantly, although there was a trend toward higher biliary complications in the DCD-V cohort (32.1% vs. 23.1%, p=0.153), which did not reach statistical significance.

Expert Commentary

The use of livers from MAiD donors introduces a unique ethical and clinical dimension to transplantation. These findings support the hypothesis that organ donation following MAiD can safely augment the donor pool without compromising outcomes. The comparable long-term graft and patient survival rates speak to the successful selection and management protocols in place. The slightly older donor age in the MAiD group may influence some clinical parameters, as suggested by the increased length of hospital stay and trend towards biliary complications, but these differences did not translate to increased graft failure or mortality.

Limitations of the study include its retrospective design and relatively limited size of the DCD-V group, which may restrict the power to detect smaller differences in complication rates. Moreover, as legislation and practice patterns vary globally, generalizability outside Canada requires consideration. Future prospective studies and mechanistic research into ischemia-reperfusion injury and biliary complications in this donor subgroup will be crucial.

Conclusions

The Canadian multicenter experience indicates that liver transplantation using grafts donated after medical assistance in dying is a viable, safe, and effective option. Comparable survival outcomes and complication rates to DCD-III donors affirm the potential to expand the liver donor pool by incorporating MAiD donors. This practice has already contributed a significant increase in DCD transplantation activity by over 20%, thus enhancing access to transplantation and honoring patients’ wishes to donate organs at end of life. Ongoing evaluation, larger cohorts, and longer follow-up will be essential to consolidate these findings and optimize clinical protocols.

References

Parente A, Verhoeff K, Ray S, Selzner M, Reichman TW, Bleszynski MS, et al. Utilization of liver grafts obtained from donation after medical assistance in dying: A Canadian multicenter experience. J Hepatol. 2026 Jan 30:S0168-8278(25)02478-X. doi: 10.1016/j.jhep.2025.08.039. Epub ahead of print. PMID: 41145323.