Normothermic Regional Perfusion in Controlled Donation After Circulatory Death: Growing Evidence for Liver Transplantation

Normothermic regional perfusion (NRP) has emerged as a pivotal strategy in controlled donation after circulatory death (cDCD) liver transplantation, mitigating ischemia-reperfusion injury and improving graft outcomes. Compared to super rapid recovery (SRR), NRP significantly reduces rates of early allograft dysfunction, primary nonfunction, and biliary non-anastomotic stricture (NAS), with biliary complications reported in 5%-16% and NAS as low as 0%-2%. Outcomes from cDCD-NRP grafts are increasingly comparable to those of donation after brain death (DBD). Viability assessment during NRP remains variably defined across centers. Nonetheless, stable pump flow, stable or declining lactate levels, controlled transaminase levels, and favorable macroscopic appearance are commonly used parameters. Histological thresholds may guide graft acceptance but are not universally applied. Sequential use of ex situ machine perfusion following NRP offers additional benefits in marginal or prolonged ischemia settings. NRP implementation has improved liver utilization rates from 34% to 63% in the United Kingdom and from 39% to 71% in the United States. This review highlights NRP as a transformative platform that reshapes viability standards, expanding transplant access, and supports sustained growth in liver transplantation.