Normothermic Machine and Regional Perfusion in US DCD Liver Transplantation

OBJECTIVE: To compare the effectiveness in US practice of normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) for donation after circulatory death (DCD) liver transplantation (LT). BACKGROUND: DCD livers historically conferred inferior outcomes to donation after brain death donors, primarily due to ischemic biliary injury. NRP and NMP have emerged as promising strategies to mitigate this risk. METHODS: Using UNOS data (2022-2024), we stratified DCD donors by procurement [super-rapid recovery (SRR) or NRP] and preservation [static cold storage (SCS) or NMP] method. NMP cases were further stratified into on-site versus back-to-base initiation of perfusion. On-site NMP was directly captured in the UNOS dataset. NRP and back-to-base NMP were identified with surrogate markers. We then compared graft (GS) and overall (OS) survival in propensity-matched cohorts. RESULTS: We identified 4632 DCD LTs. The most common procurement-preservation strategy was SRR-NMP (2637; 56.9%), followed by SRR-SCS (937; 20.2%), NRP-SCS (560; 12.1%), and NRP-NMP (498; 10.8%). SRR-NMP demonstrated superior GS (HR: 0.54, 95% CI: 0.32-0.92) versus SRR-SCS. NRP-SCS similarly reduced the risk of graft loss (HR: 0.42, 95% CI: 0.29-0.61) versus SRR-SCS. NRP-SCS and SRR-NMP had similar GS. Similarly, adding NMP to livers procured with NRP did not lead to improved outcomes compared with NRP followed by SCS. CONCLUSIONS: This study provides the most comprehensive US comparison of modern procurement and preservation strategies in DCD LT. Both NRP and NMP were associated with improved GS versus the historical standard (SRR-SCS). No significant survival differences were observed between NRP and NMP, confirming that these strategies serve complementary roles in DCD LT. These findings support the adoption of both NRP and NMP as the new standard of care in DCD LT.