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BACKGROUND: In March 2021, the United States implemented a new kidney allocation system (KAS250) for deceased donor kidney transplantation (DDKT), which eliminated the donation service area-based allocation and replaced it with a system on the basis of distance from donor hospital to transplant center within/outside a radius of 250 nautical miles. The effect of this policy on kidney discards and logistics is unknown. METHODS: We examined discards, donor-recipient characteristics, cold ischemia time (CIT), and delayed graft function (DGF) during the first 9 months of KAS250 compared with a pre-KAS250 cohort from the preceding 2 years. Changes in discards and CIT after the onset of COVID-19 and the implementation of KAS250 were evaluated using an interrupted time-series model. Changes in allocation practices (biopsy, machine perfusion, and virtual cross-match) were also evaluated. RESULTS: Post-KAS250 saw a two-fold increase in kidneys imported from nonlocal organ procurement organizations (OPO) and a higher proportion of recipients with calculated panel reactive antibody (cPRA) 81%-98% (12% versus 8%; P<0.001) and those with >5 years of pretransplant dialysis (35% versus 33%; P<0.001). CIT increased (mean 2 hours), including among local OPO kidneys. DGF was similar on adjusted analysis. Discards after KAS250 did not immediately change, but we observed a statistically significant increase over time that was independent of donor quality. Machine perfusion use decreased, whereas reliance on virtual cross-match increased, which was associated with shorter CIT. CONCLUSIONS: Early trends after KAS250 show an increase in transplant access to patients with cPRA>80% and those with longer dialysis duration, but this was accompanied by an increase in CIT and a suggestion of worsening kidney discards.
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Background: The Organ Procurement and Transplantation Network requires documentation of SARS-CoV-2 (COVID) testing status for each potential donor and lower respiratory specimen testing with nucleic acid tests for all donor lungs. In the absence of guidelines for the use of COVID-positive donor kidneys, we sought to examine the clinical characteristics of COVID-positive donors and trends in the utilization of COVID-positive donor kidneys. Method(s): This study used Scientific Registry of Transplant Recipients data and included all deceased donors (n=24,940) and recipients (n= 29,478) from June 1, 2020, through April 2, 2022. Variation in donor and recipient characteristics were considered significant at P<.05. Result(s): 1,310 (5.35%) of donors during the observation period had a positive test for COVID-19 with 1,731 (67.70%) kidneys transplanted, 108 (4.22%) not recovered, and 714 (27.92%) recovered but not transplanted. COVID-positive donors differed from COVID-negative or untested donors in terms of race, ethnicity, cause of death, and donation after circulatory death status (all P < .05). 813 recipients (2.76%) received COVID-positive deceased donor kidneys. Recipients of COVID-positive donor kidneys were more likely to be White, not have received a previous transplant, and had greater cold ischemic times (all P < .05). The number of transplants with COVID-positive donors peaked in early 2022 (Figure 1). Adjusted hazard ratios for all-cause graft failure with COVID-positive donors and death were 0.89 (95% CI, 0.62-1.28) and 0.87 (95% CI, 0.52-1.46), respectively. Conclusion(s): Transplant with COVID-positive donor kidneys increased during the study period and is not associated with increased risks for recipients. However, high discard rates for COVID-positive donors and greater cold ischemic times may suggest that such donor kidneys remain difficult to place. Patient- and transplant program-level interventions targeting decision support and risk aversion may be necessary to reduce discard rates for COVID-positive donor kidneys. (Figure Presented).
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Changes in kidney allocation coupled with the COVID-19 pandemic have placed tremendous strain on current systems of organ distribution and logistics. Although the number of deceased donors continues to rise annually in the United States, the proportion of marginal deceased donors (MDDs) is disproportionately growing. Cold ischemia times and kidney discard rates are rising in part related to inadequate planning, resources, and shortages. Complexity in kidney allocation and distribution has contributed to this dilemma. Logistical issues and the ability to reperfuse the kidney within acceptable time constraints increasingly determine clinical decision-making for organ acceptance. We have a good understanding of the phenotype of "hard to place" MDD kidneys, yet continue to promote a "one size fits all" approach to organ allocation. Allocation and transportation systems need to be agile, mobile, and flexible in order to accommodate the expanding numbers of MDD organs. By identifying "hard to place" MDD kidneys early and implementing a "fast-track" or open offer policy to expedite placement, the utilization rate of MDDs would improve dramatically. Organ allocation and distribution based on location, motivation, and innovation must lead the way. In the absence of change, we are sacrificing utility for futility and discard rates will continue to escalate.
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Purpose: The demand for kidney transplant continues to rise, and limited supply has encouraged acceptance of marginal donor organs, such as those at risk for acute kidney injury (AKI). We evaluated the utilization of such organs (defined as donation after cardiac death, pediatric donors, kidneys with a cold ischemic time >24 hrs, terminal serum creatinine (SCr) >2mg/dL or rising SCr with decreasing urine output at donation) at our center who were discharged on belatacept based maintenance immunosuppression with mycophenolate and steroids (BBMS). Method(s): This retrospective, descriptive study examined kidney transplant recipients (KTR) who received AKI organs and were discharged on BBMS between 1/2019-4/2021. Primary outcome assessed graft function and rejection at 6 & 12 months (mos) post-transplant (txp). Secondary outcomes evaluated graft failure, mortality, infection, DSA & changes to BBMS. All outcomes were evaluated at 1yr if records were available. Result(s): 68 KTR w/1 yr results & 52 w/6 mo results on BBMS were included. Baseline characteristics (Table 1) show most KTR received a DCD or en bloc organ and lymphocyte depleting induction. Mean eGFR improved from 1 to 6 mo post-txp and was stable through 1yr. Episodes of biopsy proven rejection were more common during the first 6mos post-txp. There were 2 deaths during the study period, due to COVID, and no graft failures. Twelve KTR developed DSA. There were 21 KTR with CMV viremia, mostly in moderate risk group, & 12 with BK viremia. Table 4 shows changes to BBMS occurred in 32 KTR. Most KTR required multiple BBMS changes with most common dose adjustments to mycophenolate due to leukopenia or neutropenia. Conclusion(s): Utilization of AKI organs with BBMS in KTR at our center resulted in no graft failures & sustained eGFR despite more rejection episodes during the first 6mos post-txp. Although 32 KTR had changes to BBMS, only 5 KTR had rejection following a change. Incidence of CMV was common but did not impact KTR outcomes. Overall, BBMS could be a promising option in AKI organs to avoid nephrotoxicity associated with CNI based regimens. These findings suggest the need to further evaluate the impact of long-term outcomes associated with changes made to BBMS in AKI donor organs.
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Purpose: Liver transplant recipients have a high risk of developing postoperative pulmonary complications. Pulmonary function tests (PFTs) are expensive and often incapable of predicting patients at risk or improving patient outcomes, thus a single-center implemented specific criteria to determine when a PFT is administered for the evaluation of patients for liver transplantation. The protocol recommends a PFT for patients with a history of chronic lung disease, recurrent pneumonia prior to transplant, symptomatic COVID-19 requiring hospitalization, tobacco abuse, alpha-1 antitrypsin positivity, or oxygen dependency. Method(s): We conducted a retrospective cohort study of consecutive adult patients (age greater than 18 years) who underwent deceased donor liver transplantation from January 1, 2020, to June 30, 2021. We analyzed results from pre-protocol (PRE) and post-protocol (POST) implementation. Result(s): There were a total of 215 patients in the study, 186 PRE and 29 POST protocol implementation. In the PRE group, 168 (90%) patients received PFTs compared to 12 (41%) in the POST group, p<0.001). There was no difference between the PRE and POST groups based on age in years (56 vs 55, p=0.713), male gender (65% vs 662%, p=0.83), White race (80% vs 86%, p=0.15), BMI (34 vs 28, p=0.107), or cold ischemic time in hours (5.7 vs 6, p=0.252). There was no difference in FVC (3.3 vs 3.0, p=0.84), FEV1 (2.6 vs 2.2, p=0.87), FEV1/FVC% (76.9 vs 74.4, p=0.47) and DLCO (16.4 vs 13.8, p=0.11). The postoperative variables were the same for both groups with time to extubation hours (25 vs 31, p=0.26), ICU length of stay days (8 vs 10, p=0.12), and transplant admission length of stay days (14.4 vs 17.4, p=0.36). Lastly, there was no difference between PRE and POST graft survival (p=0.69) or patient survival (p=0.08). Conclusion(s): This study demonstrates the successful implementation of a PFT protocol with a cost savings of roughly $38,000 in just three months with no impact on patient outcomes. Further research is indicated for broad-scale implementation.
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Purpose: COVID-19 pandemic has had a significant impact on access to routine healthcare in both hospitalized and out-patient settings. This impact was also noted in various aspects of pre and post-transplant care of liver transplant (LT) recipients. The aim of our study was to analyze the direct and indirect impact of COVID-19 on mortality in patients with recent LT. Method(s): We retrospectively analyzed 30-day, 6-month and 1-year mortality data from the UNOS database in adult LT recipients from 3 distinct groups;Pre-COVID (March 11- September 10, 2019: LT and immediate follow-up care before pandemic), Para-COVID (September 11- March10, 2020: LT before pandemic and follow-up care during pandemic), and COVID (March 11- September 10, 2020: LT and follow-up care during pandemic). Result(s): 12,598 LTs were performed during the study period. During COVID period, there was increase in LT for alcoholic liver disease, average MELD score was higher, LT for hepatitis C decreased, use of thymoglobulin induction decreased and waiting time was shorter. During the 30-day period, overall mortality between 3 groups remained same. In the COVID group, mortality from graft failure was higher (7.4 vs 17.9%, p=0.07), rate of infection was lower (14% vs 4.2%, p=0.039), and incidence of graft rejection prior to discharge was higher. During the 6-month follow-up, overall mortality, mortality from malignancy and COVID, and graft failure increased significantly in the COVID group. During the 1-year follow-up period, mortality was highest in COVID group over para-COVID group and lowest in the pre-COVID group. In the COVID group, increased mortality was from graft failure and COVID. Overall mortality in the study cohort directly from COVID was 7.8%, which was highest in the COVID group. Multivariable cox regression for one year mortality showed that risk factors for mortality were COVID period [Hazard Ratio (95%CI) 1.22 (1.02-1.46), p=0.027], older age of recipient, diabetes, portal vein thrombosis, ventilation at the time of transplant, hemodialysis at the time of transplant, re-transplant, and prolonged cold ischemic time. Conclusion(s): COVID-19 significantly impacted LT short term outcomes with increased mortality seen from COVID directly as well as indirectly. During COVID, cautious and lower use of immuno-suppression was likely associated with higher rates of rejection and lower rates of infection. Disruptions in routine post-transplant follow-up likely contributed to increased death from graft failure, malignancy, and poor control of chronic medical conditions like diabetes. (Figure Presented).
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Purpose: Effective March 15, 2021, the OPTN launched a new policy for matching kidney and pancreas transplant candidates with organs from deceased donors. The new policy was projected to increase equity in transplant access for candidates nationwide by using a scoring system based on a reference of 250 nautical mile radius from donor hospital. Various factors can influence the transplant rates including wait list size, organ acceptance practices as well as access to transplant centers in rural and socio-economically disadvantaged parts of the country. Small volume centers have short waitlist and candidates lower on the national list. With the current change in allocation, they may be forced to accept high risk kidneys. The new allocation may impact outcomes for such centers to stay active and maintain volumes. We propose to evaluate the impact of the allocation change on the kidney transplant practices at our center situated in rural setting. Method(s): A cohort study was designed comparing transplant characteristics of all patients undergoing kidney transplant at our center. The study population was all patients who had a kidney transplant after March 15, 2021. The cohort group was all patients who underwent a kidney transplant at our center from Jan 1, 2019 to Dec 31, 2019. The year 2020 was not considered because of COVID-19 pandemic. Data collected included donor demographics, recipient demographics, donor quality indices and recipient allograft function, transplant related complications. Result(s): There were 66 patients in the pre and the 49 in post allocation group. The most common cause of renal failure was diabetes in both. There were no statistically significant differences in recipient demographics. There was a dramatic increase in the number of DCD donors (48% pre vs 80% post, p 0.007). The cold ischemia time was significantly increased (20hr 5m pre vs 23hr 45m post, p 0.002). The serum creatinine trend showed higher serum creatinine at 1, 3 and 6 months post transplant in the post allocation group. Delayed graft function was seen in 3% in pre vs 10% in post group. There was an increase in hospital stay (6 days vs 8 days). Conclusion(s): The new allocation system may increase utilization DCD kidneys. It also prolongs cold ischemia time. This can result in prolonged hospital stay and DGF rates and result in higher serum creatinine levels. The impact of this on low volume centers and rural hospital systems may decrease organ transplant rates in such areas and lead to disparity in transplant access.
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Purpose: At the beginning of the pandemic, kidneys from SARS-CoV-2 (COVID) RT-PCR positive donors were not utilized for transplantation, due to the risk of viral transmission. With the advent of the COVID vaccines, and improved monoclonal antibody therapy we transplanted organs from COVID positive donors irrespective of disease severity. Method(s): We performed six kidney transplants from COVID RT-PCR positive donors. Potential donors were screened for the date of the first positive COVID RTPCR. Only donors whose test had been positive at least 10 days prior to donation on a nasopharyngeal swab or bronchoalveolar lavage were accepted. A cycle threshold (ct)of >= 35 cycles was used as a cut off for accepting kidneys, when results were available prior to donation. Disease severity was not considered in donor evaluation. Recipient selection was performed based on willingness to give informed consent for the use of such kidneys, prior vaccination with at least 2 doses of the COVID vaccine and negative RT-PCRs in the month prior to transplantation. Result(s): We successfully transplanted 6 recipients from 5 donors. While one of the kidneys was recovered locally, the remainder were imported as non mandatory nationally shared organs. Four donors suffered from ARDS secondary to COVID pneumonia. Two donors were on ECMO at the time of donation. Two of the 5 donors were DCD recoveries with warm ischemic times times of 22 and 28 minutes. Co-infections in the donors included Candida glabrata, Enterococcus faecalis, and Burkholderia Cepacia for which appropriate prophylaxis was used in the recipients. All donors had positive nasopharyngeal RT-PCRs. Three had positive bronchioloalveolar lavage RT-PCRs. One donor was RT-PCR negative at the time of donation. Three recipients were sensitized with a PRA of 48%, 96%and 100%. The mean cold ischemic time was 25 hours. The mean KDPI was 51%. The delayed graft function rate was 33%. There was no primary nonfunction, rejection, death or graft loss after median follow-up of 87 (30-250days). The mean recipient GFR was 43ml/min. Dual kidney transplants were performed in two recipients. None of the recipients developed a COVID infection. 5/6 recipients received monoclonal antibodies (casirivimab and imdevimab) immediately after reperfusion. One patient did not receive casirivimab and imdevimab as it was not yet available in our region. All 6 patients received Thymoglobulin induction. Conclusion(s): With careful selection of immunized recipients, clinical assessment of transmission risk, and the preemptive use of monoclonal antibodies post exposure , SARS-Cov-2 positive donor kidneys can be safely utilized for single or dual kidney transplantation, without an increased risk of viral transmission, rejection or graft loss.
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Purpose: Acuity circles (AC) allocation was implemented on 2/4/2020 with a goal of removing DSA and region from liver allocation and broadening the distribution of livers, particularly for highly medically urgent candidates. Method(s): OPTN waitlist and transplant data was analyzed 18 months pre- (8/6/2018- 2/3/2020) and post- (2/4/2020-8/3/2021) AC implementation. Result(s): Post-policy, there were 448 more adult (age 18+ at listing) and 83 less pediatric (<18 at listing) waitlist additions, 570 more adult (age 18+ at transplant) and 4 less pediatric (<18 at transplant) deceased donor liver-alone transplants, and 121 less adult and 12 less pediatric removals for death or too sick. Transplant rates significantly increased overall post-policy, notably in the most medically urgent groups (Figure 1). The national median transplant score for adults remained unchanged at 28 and decreased from 35 to 30 for pediatric transplant recipients, likely due to the increased number of adolescents (age 12-17) transplanted at MELD scores under 29. There was a noticeable shift in the distribution of distance between donor hospital and transplant program, particularly for the most medically urgent groups where larger proportions of livers are coming from 250-500 NMs (Figure 2). Despite this change, median cold ischemia time increased only 11 minutes for adult recipients and 33 minutes for pediatric recipients post-policy. One year post transplant patient survival decreased from 94% pre-policy to 93% post-policy (p=0.02). Conclusion(s): Broader allocation increased transplant rates and livers are traveling longer distances for candidates with greater medical urgency with little effect on cold ischemia time and post-transplant survival. Unfortunately, AC implementation was followed shortly by COVID-19 making it difficult to parse out COVID-19 from potential policy effects. Metrics will continue to be monitored as more data become available. (Figure Presented).
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The proceedings contain 1892 papers. The topics discussed include: organs from donors with positive SARS-CoV-2 NAT+ testing: a report from the ad hoc disease transmission advisory committee;targeted delivery of costimulation inhibitor to lymph nodes promotes transplant tolerance via fibroblastic reticular cells;biomarker initiative to advance transplantation outcomes in children (BRITE-c) analysis;site-directed mutagenesis as a tool to investigate immunogenicity of HLA epitopes for humoral alloreactivity;changes in cold ischemia time and transplantation practices with the concentric model of kidney allocation;transplant rates increased with broader distribution of deceased donor kidneys;identical kidneys are discarded at higher rates when labeled as High KDPI;implications of accumulated cold time for US kidney transplantation offer acceptance;physician preferences when selecting candidates for marginal quality kidney offers: a discrete choice experiment;and patient preferences for waiting time and kidney quality: a discrete choice experiment.
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Background: With the growing acceptance of the role for the expansion of suitable indications for liver transplantation, such as selected cases of hilar cholangiocarcinoma and unresectable colorectal liver metastases, the imbalance between clinical need for liver transplantation and supply of suitable donor organs is likely to widen in Europe for the foreseeable future. Novel organ perfusion technologies are likely to play a fundamental role in maximising utilisation of all donor organs and facilitating the safe transplantation of marginal grafts. Herein we describe the initial experience of implementing Normothermic Machine Perfusion (NMP) in a liver transplant centre just before the onset of the COVID-19 pandemic. Methods: Retrospective analysis of a prospectively-maintained comprehensive database encompassing donor characteristics, perfusion parameters and post-transplantation outcomes. Results: Between February 2020 and October 2021 (20 months), 37 liver grafts were perfused with NMP and 23 proceeded to transplantation. The indications for NMP included logistics - 16 grafts (69%), further assessment of marginal grafts - 5 (22%) livers and facilitation of a predicted difficult hepatectomy (e.g. redo transplant) - 2 livers (9%). Overall, a total of an additional 15 livers, 3 kidneys and one pancreas were transplanted that absolutely could not have been transplanted without NMP (e.g. logistics, unacceptable cold ischaemic time with static cold storage) and a further 7 livers were successfully transplanted that may have been declined without the additional reassurance of dynamic functional assessment and safe prolongation of preservation time. No grafts were lost as a result of perfusion with NMP. Conclusions: NMP is a safe and effective technique for improving graft utilisation in liver transplantation and has become an integral component of routine clinical practice since its introduction in Edinburgh. As collective experience with NMP increases, the prognostic predictive ability of serum (and potentially bile) analysis on the machine is likely to improve graft utilisation further.
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Background: Traditionally, patients were kept intubated for 48 hours in the postoperative period. Living donor liver transplantation poses a different set of challenges. Most of the predictors mentioned in the literature were, low MELD, low BMI, and with stable comorbidities etc. for early extubation following living donor liver transplantation. We assessed the feasibility of fast tracking and early extubation in our patients, who were not fitting in those mentioned predictors in the literature. Methods: We present a case series of 6 patients who were fast tracked and extubated early, following living donor liver transplantation, out of 22 patients over the last 6 months. Results: All these patients were aged more than 45 yrs, with an average age of 55.8 yrs, average MELD score of 20.8, Child status C, some of our patients had cardio pulmonary comorbidities. patient 2, was COPD, post asymptomatic COVID, with CoRad score3 on HRCT, patient 5, was class 3 obese with no OSA, patient 6, had Hypertension, CAD- triple vessel disease, post CABG 7 yrs back, The intraoperative metabolic parameters like base excess and Lactates were showing good correction and all of them had very minimal inotropic support at the time of extubation, with Norepinephrine < 0.05mcg/kg/minutes. There was no post reperfusion hemodynamic instability or PRS in our patients, the average GRWR in our patients was 0.94, the mean anhepatic period, warm ischemia and cold ischemia times were pretty low. None of them had any significant postoperative complications. Conclusions: We propose, we can safely fast track and extubate early, following living donor liver transplantation with high MELD scores, and stable comorbidities. Further, large studies are needed to look for the feasibility of expanding the criteria for early extubation.
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BACKGROUND AND AIMS: Our modern world is facing extraordinary circumstances while passing through a serious pandemic caused by the novel coronavirus (COVID-19) which may lead to multi-organ system failure and death. COVID-19 deaths may provide a potential source for kidneys available for transplantation. In our study, we are discussing the safety of receiving kidneys from donors who tested positive for the novel coronavirus. METHOD: All renal transplant recipients registered in UNOS database who had their transplants between 1 March 2020 and 1 June 2021 were retrospectively reviewed. Patients who received kidney transplants from a deceased donor with positive PCR of COVID-19 test were included in our study. Patients were followed up till 1 July 2021. Data about recipient factors (age, sex, ethnicity, diabetes and date of renal transplant), transplant factors (type of induction therapy, maintenance immunosuppressive therapy, delayed graft functions, early post-operative rejection episodes, HLA mismatch, PRA level and cold ischemia time) and donor factors (age, sex, ethnicity, diabetes, hypertension, date of COVID-19 test and type of COVID-19 test) were collected. Outcome measured were post-transplant hospitalisation, acute rejection, delayed graft function, patient, and graft survival till the end of the follow-up. RESULTS: Eighty-six transplant patients received kidneys from deceased donors who tested positive for COVID-19 infection using PCR test. Sixty patients received kidneys from deceased patients who tested positive for COVID-19 within 30 days pre-transplant. Twenty-six patients received kidneys from deceased patients who tested positive for COVID-19 between 30 and 90 days pre-transplant. Number of post-transplant hospitalisation and acute rejection episodes were nil. 19.76% of the patients had delayed graft functions. Graft loss occurred in one patient due to graft vein thrombosis. Patient survival was 100%. CONCLUSION: Receiving kidneys from deceased donors who tested positive for COVID-19 infection seems safe and does not affect hospitalisation, acute rejection rates, graft or patient survival. Longer follow-up is needed to confirm our results.
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Introduction: Extended criteria donors (ECD) in liver transplantation (LT) is gaining worldwide acceptance due to the shortage of optimal donors. Most of liver transplant groups agree that ager over 60, prolonged cold ischemia time (CIT), steatosis, inotropic support, non-heart beating donors (NHBD), sustained hypernatremia, split livers among other factors are related to primary non-function (PNF) with high morbimortality. Before COVID-19 pandemia discarded liver grafts that nobody wants accounts for the double of LT done each year in Mexico and it seems that there is an increasing rate of marginal or ECD. To define discarded liver grafts, these must be refused by 3 of the main liver transplant centers in the country and have ≥ 3 risk factors for PNF and delayed graft function (DGF). Method: A period from january 2015 to january 2021 was observed. Donor characteristics such sustained severe hypernatremia (>165 mEq/l), moderate steatosis (>40%), body mass index (BMI) >30 k/m2, alcohol abuse, CIT >12 h and norepinephrine support were considered risk factors for PNF and DGF. DGF, PNF, morbidity and mortality were evaluated. Result: 159 LT were done. Marginal donors 61 (38.3%), discarded livers 40 (65.5%). Severe hypernatremia (165-188 mEq/l) 20 (50%), obesity (BMI 30-45k/m2) 30 (75%), moderate to severe steatosis (40-76%) 22 (55%), alcohol abuse in 3 (7.5%), age >60 (35%) and norepinephrine support 27 (67%). No CIT > 12 h was recorded. PNF between marginal and discarded liver grafts were the same (5%) and between optimal grafts and discarded or marginal the rate of PNF were 2.1 to 5%. DGF was present in 7.5%, 5% and 3.1% of discarded, marginal and optimal grafts respectively. No differences in mortality rate between groups. Conclusion: Discarded livers are an acceptable choice to expand liver donor pool in Mexico. None hypernatremia, obesity, steatosis or age are independent poor risk factors for developing PNF.