Donor Time to Death and DCD Liver Transplant Outcomes: Challenging the Dogma That Shorter Is Better

Background: In circulatory death transplantation, time to death (TTD) following withdrawal of life-sustaining treatment is unpredictable. Concerns persist that prolonged TTD may cause ischemic injury, resulting in organ nonuse. We assessed the impact of donor TTD on liver transplant outcomes and utilization. Methods: We used Organ Procurement and Transplantation Network data on adult donors after circulatory death transplants (2010-2025). Multivariable nonlinear (restricted cubic splines) regression models were used to analyze associations. Simulation studies estimated potential increases in liver acceptance rates. Results: In 8489 recipients, short donor TTD was associated with inferior outcome, contrary to popular belief. Prolonged TTD did not show inferior posttransplant outcomes, irrespective of whether normothermic regional perfusion (NRP) was used. Nonlinear modeling (n = 37 447) revealed a sharp decline in utilization once TTD exceeded just 15 min. Given prolonged TTD did not impact outcomes, these declines represent a missed opportunity for organ use. Simulation studies revealed that if surgeons assess organ offers from patients with TTD of 15-30 min identically to those with TTD