Impact of Normothermic Regional Perfusion on Clinical Outcomes in Kidney Transplantation From Donors After Circulatory Death

OBJECTIVE: We evaluated the impact of normothermic regional perfusion (NRP) on short and mid-term outcomes of kidney transplantation (KT) using donation after circulatory death (DCD). We further examined the influence of NRP duration and identified subgroups most likely to benefit from its use. BACKGROUND: NRP has recently gained adoption in DCD-KT as a means to mitigate donor warm ischemic injury. However, its effect on graft and patient outcomes, particularly beyond 1 year, remains uncertain, and the role of NRP duration and subgroup-specific benefits has not been well defined. PATIENTS AND METHODS: Using United Network for Organ Sharing Standard Transplant Analysis and Research files, we analyzed 21,010 primary adult DCD-KT cases performed between 2020 and 2025. Based on prior literature, cases were classified as non-NRP (0 to 30 minutes from circulatory death to cross-clamp) or NRP (30 to 180 minutes). Propensity score matching adjusted for donor and recipient differences. Kaplan-Meier methods assessed graft and patient survival. RESULTS: After propensity score matching, NRP was associated with reduced delayed graft function (30.3% vs 49.7%), shorter hospital stay (median: 4 vs 5 days), and improved overall graft and patient survival ( P = 0.007 and 0.047). No difference was observed in overall graft survival between short and long NRP durations ( P = 0.62). Subgroup analyses for 1-year graft survival revealed that the benefit of NRP was more evident in cases of elderly recipients or donors, high donor body mass index, higher Kidney Donor Profile Index, and prolonged pretransplant dialysis. CONCLUSIONS: NRP improved both short- and mid-term outcomes, including 3-year/overall graft/patient survival. NRP duration did not significantly affect overall graft survival. The benefits of NRP were pronounced in high-risk subgroups.