Impact of the Donor Risk Index on the Outcome
of Hepatitis C Virus–Positive Liver Transplant
Daniel G. Maluf,1Erick B. Edwards,3R. Todd Stravitz,2and H. Myron Kauffman3†
1Division of Transplantation Surgery and2Section of Hepatology, Hume-Lee Transplant Center, Virginia
Commonwealth University, Richmond, VA; and3United Network for Organ Sharing, Richmond, VA
We have investigated the impact of the donor risk index (DRI) on the outcome of hepatitis C virus (HCV)–infected patients
undergoing liver transplantation (LTx). Retrospective analysis was performed from the Organ Procurement and Transplantation
Network database (January 1, 2000 to June, 2006). The DRI was calculated as described by Feng et al. (Am J Transplant
2006;6:783-790). Model for End-Stage Liver Disease (MELD) exceptions were excluded from the analysis. Relative risk (RR)
estimates of patient and graft loss were derived from Cox regression models. The Wald test was used to test the effect of the MELD
score at transplant on the HCV-DRI interaction. Of the LTx recipients (16,678), 76.1% were Caucasian, and 66.7% were male; the
median age was 52 (range, 18-80 years), and the mean follow-up time was 1148 days (range, 0-2959 days). Forty-six percent (n ?
significant increase in the RR of graft failure and patient death for both HCV(?) and HCV(?) recipients. However, HCV(?) recipients
demonstrated a significantly higher increase in the RR of patient and graft loss as a function of the DRI than HCV(?) subjects, even
after adjustments for several recipient factors, including MELD. In conclusion, a synergistic interaction between donor DRI and
recipient HCV status exists, such that an allograft from a high-DRI donor more adversely affects the outcome of an HCV(?) recipient
than that of an HCV(?) recipient. Liver Transpl 15:592-599, 2009. © 2009 AASLD.
Received May 6, 2008; accepted October 26, 2008.
See Editorial on Page 570
Liver transplantation (LTx) is an effective therapy of last
resort in patients with end-stage liver disease, of whom
approximately 40% to 50% have cirrhosis due to infec-
tion with hepatitis C virus (HCV). Advances in surgical
techniques and perioperative management have greatly
improved patient and graft survival post-LTx in the past
Even though the number of liver transplants per-
formed in the United States has increased in the last
years (from 5000 to 6400 between 2000 and 2007) and
the number of new registrations on the waiting list has
remained relatively constant over the same time frame
(10,751 and 11,080 patients, respectively),2the gap
between organ availability and listed patients continues
to result in considerable waitlist mortality, keeping the
issue of organ allocation at the forefront of discussions
within the transplant community. Techniques such as
living donor liver transplantation (LDLTx), split or par-
tial LTx, donation after cardiac death, and the utiliza-
tion of marginal or extended criteria donor grafts have
evolved in the past decade to help meet this need. Cur-
rently, LDLTx accounts for close to 5% of liver trans-
plants in the United States, and despite the rapid in-
crease in the number of centers performing LDLTx
Abbreviations: CI, confidence interval; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; DRI, donor risk
index; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; ICU, intensive care unit; LDLTx, living donor liver transplantation; LTx,
liver transplantation; MELD, Model for End-Stage Liver Disease; NS, not significant; OPTN, Organ Procurement and Transplantation
Network; RR, relative risk; SRTR, Scientific Registry of Transplant Recipients; TIPS, transjugular intrahepatic portosystemic shunt.
Additional Supporting Information may be found in the online version of this article.
Address reprint requests to Daniel G. Maluf, M.D., Department of Surgery, Virginia Commonwealth University, West Hospital 9th Floor, P.O. Box
980057, Richmond, VA 23298-0248. Telephone: 804-628-3956; FAX: 804-828-4858; E-mail: firstname.lastname@example.org
Published online in Wiley InterScience (www.interscience.wiley.com).
LIVER TRANSPLANTATION 15:592-599, 2009
© 2009 American Association for the Study of Liver Diseases.
HCV(?) group would likely decrease the magnitude of
In summary, we identified a synergistic, adverse inter-
action between donor DRI and recipient HCV status that
increased risk of graft and patient loss in HCV(?) LTx
recipients per unit increase of the DRI. This observation
the donor’s presentation as defined by the DRI, affect
long-term transplant outcome. High-DRI grafts should be
used carefully in HCV(?) patients. However, even though
MELD does not affect this interaction, the high risk of
mortality in recipients with high MELD scores (?20) may
still justify the use of a high-DRI graft.
We dedicate this article to the memory of our senior
author and colleague, Dr. H. Myron Kauffman, whose
constant enthusiasm and support enlightened the field
of organ transplantation.
1. Roberts MS, Angus DC, Bryce CL, Valenta Z, Weissfeld L.
Survival after liver transplantation in the United States: a
disease-specific analysis of the UNOS database. Liver
2. Organ Procurement and Transplantation Network. Avail-
able at: www.optn.org. Accessed October 2008.
3. Mutimer DJ, Gunson B, Chen J, Berenguer J, Neuhaus P,
Castaing D, et al. Impact of donor age and year of trans-
plantation on graft and patient survival following liver
transplantation for hepatitis C virus. Transplantation
4. Feng S, Goodrich NP, Bragg-Gresham JL, Dykstra DM,
Punch JD, Debroy MA, et al. Characteristics associated
with liver graft failure: the concept of a donor risk index.
Am J Transplant 2006;6:783-790.
5. Cameron AM, Ghobrial RM, Yersiz H, Farmer DG, Lip-
shutz GS, Gordon SA, et al. Optimal utilization of donor
grafts with extended criteria. A single-center experience in
over 1000 liver transplant. Ann Surg 2006;6:748-753.
6. Berenguer M, Prieto M, San Juan F, Rayo ´n JM, Martinez
F, Carrasco D, et al. Contribution of donor age to the
recent decrease in patient survival among HCV-infected
liver transplant recipients. Hepatology 2002;36:202-210.
7. Forman LM, Lewis JD, Berlin JA, Feldman HI, Lucey MR.
The association between hepatitis C infection and survival
after orthotopic liver transplantation. Gastroenterology
8. Berenguer M, Ferrell L, Watson J, Prieto M, Kim M, Rayo ´n
M, et al. HCV-related fibrosis progression following liver
transplantation: increase in recent years. J Hepatol 2000;
9. Neumann UP, Berg T, Bahra M, Seehofer D, Langrehr JM,
Neuhaus R, et al. Fibrosis progression after liver trans-
plantation in patients with recurrent hepatitis C. J Hepa-
10. Gayowski T, Marino IR, Singh N, Doyle H, Wagener M,
Fung JJ, Starzl TE. Orthotopic liver transplantation in
high-risk patients: risk factors associated with mortality
and infectious morbidity. Transplantation 1998;65:499-
11. Yilmaz N, Shiffman ML, Stravitz RT, Sterling RK, Luketic VA,
Sanyal AJ, et al. A prospective evaluation of fibrosis progres-
sion in patients with recurrent hepatitis C virus following
liver transplantation. Liver Transpl 2007;13:975-983.
12. Bigam DL, Pennington JJ, Carpentier A, Wanless IR,
Hemming AW, Croxford R, et al. Hepatitis C-related cir-
rhosis: a predictor of diabetes after liver transplantation.
13. Asfandiyar S, Abouljoud M, Kim D, Brown K, Yoshida A,
Arenas J, et al. Influence of hepatitis C on renal function
after liver transplantation. Transplant Proc 2006;38:
14. Busuttil RW, Tanaka K. The utility of marginal donors in
liver transplantation. Liver Transpl 2003;9:651-663.
15. De Carlis L, Colella G, Sansalone CV, Aseni P, Rondinara
GF, Slim AO, et al. Marginal donors in liver transplanta-
tion: the role of donor age. Transplant Proc 1999;31:397-
16. Agnes S, Avolio AW, Magalini SC, Grieco G, Castagneto M.
Marginal donors for patients on regular waiting list for
liver transplantation. Transpl Int 1996;9:469-471.
17. Maluf DG, Edwards EB, Kauffman HM. Utilization of ex-
tended donor criteria liver allograft: is the elevated risk of
failure independent of the Model for End-Stage Liver Dis-
ease score of the recipient? Transplantation 2006;82:
18. Berenguer M, Lopez-Labrador FX, Wright TL. Hepatitis C
and liver transplantation. J Hepatol 2001;35:666-678.
19. Berenguer M, Prieto M, Rayo ´n JM, Mora J, Pastor M, Ortiz
V, et al. Natural history of clinically compensated hepatitis
C virus-related graft cirrhosis after liver transplantation.
20. Berenguer M. Management of hepatitis C virus in the
transplant patient. Clin Liver Dis 2006;11:355-376.
21. Wall W, Khakhar A. Retransplantation for recurrent hep-
atitis C: the argument against. Liver Transpl 2003;9:S73–
22. Mottershead M, Neuberger J. Grafts and hepatitis C virus:
maximizing the benefit. Liver Transpl 2007;13:947-952.
23. Lake JR, Shorr JS, Steffen BJ, Chu AH, Gordon RD,
Wiesner RH. Differential effects of donor age in liver trans-
plant recipients infected with hepatitis B, hepatitis C and
without viral hepatitis. Am J Transplant 2005;5:549-557.
24. Rayhill SC, Wu YM, Katz DA, Voigt MD, Labrecque DR,
Kirby PA, et al. Older donor livers show early severe his-
tological activity and graft failure after liver transplanta-
tion for hepatitis C. Transplantation 2007;84:331-339.
25. Baccarani U, Adani GL, Toniutto P, Sainz M, Lorenzin D,
Viale PL, et al. Liver transplantation from old donors into
HCV and non-HCV recipients. Transplant Proc 2004;36:
26. Cescon M, Grazi GL, Ercolani G, Nardo B, Ravaioli M,
Gardini A, Cavallari A. Long-term survival of recipients of
liver grafts from donors older than 80 years: is it achiev-
able? Liver Transpl 2003;9:1174-1180.
27. Poordad, F. Liver transplant and recurrent disease: hep-
atitis B. Clin Liver Dis 2004;8:461-473.
28. Wiesner R, Sorrell M, Villamil F, for the International Liver
Transplantation Society Expert Panel. Report of the first
International Liver Transplantation Society expert panel
consensus conference on liver transplantation and hepa-
titis C. Liver Transpl 2003;9:S1–S9.
29. Rosen HR, Chou S, Corless CL, Gretch DR, Flora KD,
Boudousquie A, et al. Cytomegalovirus viremia: risk factor
for allograft cirrhosis after liver transplantation for hepa-
titis C. Transplantation 1997;64:721-726.
30. Khapra AP, Agarwal K, Fiel MI, Kontorinis N, Hossain S,
Emre S, Schiano TD. Impact of donor age on survival and
fibrosis progression in patients with hepatitis C undergo-
ing liver transplantation using HCV? allografts. Liver
31. Waki K. UNOS Liver Registry: ten year survivals. Clin
IMPACT OF THE DONOR RISK INDEX 599
LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases