Transforming the logistics of liver transplantation with normothermic machine perfusion: Clinical impact versus cost

Normothermic machine perfusion (NMP) facilitates the utilization of marginal liver allografts. It remains unknown whether clinical benefits offset additional costs in the real-world setting. We performed a comparison of outcomes and hospitalization costs for donor livers preserved by NMP versus static cold storage at a high-volume center. Adult patients receiving deceased donor liver transplants preserved by either NMP (TransMedics Organ Care System) or static cold storage between January 1, 2021, and December 31, 2023, were included. Donor and recipient characteristics, operative parameters, post-transplant outcomes, and hospitalization costs were compared. A total of 144 NMP and 149 static cold storage cases were included. A higher proportion of NMP cases were donation after circulatory death (38.2% vs. 4.7%, p <0.001). Despite a significantly higher Liver Donor Risk Index (2.1 vs. 1.7, p <0.001) and longer preservation time (877 vs. 355 min, p <0.001), recipients of NMP experienced lower rates of reperfusion syndrome (4.3% vs. 32.9%, p <0.001), less blood loss (1.5 vs. 3.0 L, p <0.001), and required less blood product transfusion. This resulted in shorter operative time for NMP cases (357 vs. 438 min, p <0.001) and significant reductions in both intensive care unit (3 vs. 5 d, p =0.005) and hospital length of stay (11 vs. 13 d, p =0.03). NMP facilitated the transition of cases to daytime hours (88.9% vs. 46.3%, p <0.001). Despite the clinical and logistical benefits observed, index hospitalization costs were significantly higher in the NMP cohort ($256,810 vs. $209,144, p <0.001), driven largely by higher organ acquisition costs ($135,930 vs. $50,940, p <0.001). In conclusion, utilization of NMP comes with an attendant increase in cost but provides substantial clinical benefit. Transplant programs must weigh these considerations in their practice environments before initiating an NMP program.