A journey from marginality to routine and beyond: single center experience with DCD utilization for liver transplantation in Italy.

Donation after cardiovascular determination of death (DCD) has expanded the liver donor pool but remains limited by concerns over prolonged donor warm ischemia and inferior outcomes, particularly in countries such as Italy where legally mandated asystolic periods increase donor risk. This study evaluates trends in DCD liver transplantation at a high-volume Italian center, to assess whether accumulated experience and advanced reconditioning strategies influenced outcomes over time. We retrospectively analyzed adult DCD liver transplants performed between 2016 and 2023. Donor characteristics, recipient risk profiles, perfusion strategies, ischemia times, and post-transplant outcomes were compared between an early (2016-2021) and a late (2022-2023) period. Temporal trends were evaluated using linear regression. Seventy-five DCD liver transplants were included. Later-period recipients had more advanced liver disease (39.1% vs. 17.2% Child-Pugh C, p = 0.045) and higher P-SOFT and LTRS risk scores. Moreover, later-period donors were older (median 72 vs. 62 years, p = 0.022), and exhibited higher DRI and ET-DRI scores. Concurrently, HOPE duration increased, and total ischemia time decreased linearly with program maturation. Despite the progressive rise in donor and recipient risk, rates of early allograft dysfunction, biliary complications, retransplantations, and graft and patient survival remained unchanged between periods. In a high-risk regulatory setting, DCD liver transplantation outcomes remained stable despite increasing donor and recipient complexity. Program maturation, ischemia minimization, and prolonged hypothermic oxygenated perfusion appear to effectively mitigate DCD-associated risk, supporting broader and safer utilization of DCD liver grafts even in challenging clinical environments.