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Normothermic Machine and Regional Perfusion in U.S. DCD Liver Transplantation: A Comparative Analysis Supporting Adoption as the Standard of Care
*Sergio Acuna
1, *Hiren Dayala
1, *Maggie E. Jones-Carr
2, *Paul MacLennan
1, Devin E. Eckhoff
3,
*Robert M. Cannon11Surgery, University of Alabama at Birmingham, Birmingham, Alabama; 2Surgery, University of Mississippi, Jackson, Mississippi; 3Surgery, Beth Israel Deaconess, Boston, Massachusetts
Background: Livers from donation after circulatory death (DCD) donors historically conferred inferior outcomes to donation after brain death donors, primarily due to increased rates of ischemic biliary injury. Normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) have emerged as promising strategies to mitigate the ischemia-related risks of DCD liver transplantation, but their comparative effectiveness in U.S. practice remains under investigation.
Methods: Using United Network for Organ Sharing data (January 2022 - December 2024), we stratified DCD donors by procurement (super rapid recovery [SRR] vs. NRP) and preservation (static cold storage [SCS] vs. NMP) method. Use of NMP was further categorized as on-site vs. back to base. Onsite NMP was directly captured in the UNOS dataset. Utilization of NRP and back-to-base NMP were identified with surrogate markers utilized by the literature and Scientific Registry of Transplant Recipients. NMP cases were further stratified into on-site versus back to base initiation of perfusion. We then then compared graft (GS) survival in propensity matched cohorts defined by procurement and preservation strategy.
Results: There were 5,084 patients undergoing DCD LT in the study period. The most common procurement-preservation strategy was SRR with NMP (2,855; 56.2%), followed by SRR with SCS (1,171; 23%), NRP with SCS (560; 11%), and NRP with NMP (498; 9.8%). SRR-NMP was associated with superior GS (HR 0.46, 95%CI 0.33-0.65) vs. SRR-SCS, but this was only present when NMP was initiated at the donor hospital (figure). NRP-SCS similarly was associated with reduced risk of graft loss (HR 0.44, 95%CI 0.26-0.73) versus SRR-SCS. Direct comparison of NRP-SCS and SRR-NMP showed no significant differences in GS (figure). Similarly, adding NMP to livers procured with NRP was not associated with improved outcomes compared to NRP followed by SCS (figure).
Conclusions: This study provides the most comprehensive U.S. comparison of modern procurement and preservation strategies in DCD liver transplantation. Both NRP and NMP applied in isolation were associated with improved graft survival vs. SRR-SCS. No significant survival differences were observed between NRP and NMP, confirming their complementary roles in DCD liver transplantation. These findings support the adoption of either NRP or NMP as the new standard of care in DCD liver transplantation.
Figure: Graft survival comparison among different procurement and preservation strategies.
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