Improving outcomes in donation after circulatory death vs. donation after brain death liver transplantation for acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) carries high short-term mortality, and liver transplantation (LT) remains the curative treatment. Donation after circulatory death (DCD) grafts expand the donor pool but carry higher risks of dysfunction compared to donation after brain death (DBD) grafts, and data directly comparing their outcomes in ACLF are limited. Using the Scientific Registry of Transplant Recipients (SRTR), we conducted a retrospective cohort study of 67,201 adult LT recipients from 2004 to 2023, stratified into three eras (Era 1: 2004-2012, Era 2: 2013-2018, Era 3: 2019-2023). Patients with prior LT, fulminant liver failure (status 1A), active hepatocellular carcinoma, or multivisceral transplants (excluding liver-kidney) were excluded. Estimated ACLF (EST-ACLF) severity was defined using EASL-CLIF criteria. One-year graft failure and survival were assessed using multivariable Cox regression and Kaplan-Meier analyses. Of 67,201 recipients, 62,510 received DBD and 4,691 DCD grafts. DCD grafts did not show clinically meaningful differences in 1-year hazards of graft failure compared to DBD grafts. One-year graft survival in EST-ACLF-2/3 improved over time from 87.2% in Era 1%-96.0% in Era 3, approaching the 97.5% observed with DBD grafts. DCD grafts may represent a viable and increasingly safe strategy for expanding LT access in ACLF.