The impact of neurologic exam on acceptance of donation after circulatory death liver allografts.

While donation after circulatory death (DCD) has contributed significantly to growth in liver transplantation volume, 70%-80% of DCD liver allografts remain nonutilized. We suspected that neurologic exam documentation fuels concerns that potential donors would not expire within an acceptable time frame, thus discouraging the pursuit of organs. We hypothesized that the neurologic exam is an unreliable predictor of donor warm ischemia time (DWIT), but nevertheless influences clinicians' behavior with respect to organ acceptance. We conducted a retrospective study of 11,967 adult potential DCD donors in the Standard Transplant Analysis and Research file (2011-2020). Multivariable logistic regression was performed to evaluate the association between neurologic exam documentation and acceptance of liver allografts. To assess the value of neurologic exam parameters in predicting successful donations, we calculated test characteristics of positive brainstem reflexes (BSRs) for DWIT >30/60 minutes. We constructed ROC curves for the number of positive BSRs in predicting DWIT >30/60 minutes. Neurologic exam documentation was available for 6,088/11,967 (50.87%) potential DCD donors. There was no association between documentation of neurologic exam (vs. nondocumentation) and acceptance. However, documentation of positive BSRs was associated with decreased odds of acceptance. Individual BSRs were imperfect predictors of DWIT >30/60 minutes, with sensitivities in the 50%-80% range and specificities in the 30%-60% range. ROC curves for predicting DWIT by number of positive BSRs had areas under the curve of 0.58 and 0.66 for DWIT >30 and 60 minutes. Therefore, we concluded that documentation of positive BSRs is associated with nonutilization of DCD liver allografts, despite having limited ability to predict donor expiration within the appropriate time frame for a successful DCD donation.