Cost of Normothermic Regional Perfusion vs Normothermic Machine Perfusion in DCD Liver Transplants: A Markov Decision Analysis

Introduction:The advent of perfusion technologies has increased utilization of liver allografts from donation after circulatory (DCD) donors.Further, studies indicate both normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) reduce rates of ischemic cholangiopathy.There is still a debate on the optimal perfusion modality as there is minimal data directly comparing cost and outcomes between NRP and NMP.Methods: A decision analytic Markov state transition model was created to simulate the outcomes of a cohort of 1,000 patients waitlisted for liver transplantation (Figure 1).The base case patient was a 50-year-old male on the liver transplant waitlist.State transitions to DCD liver transplant with functioning graft, DCD liver transplant with ischemic cholangiopathy, re-listed due to graft failure, re-transplant, and death were modeled, as well as associated costs.Markov parameters were extracted from current published literature.Results: Cost-utility analysis demonstrates that the average total cost of a DCD liver transplant from an NRP procurement in a 1,000 patient population is $316,000 compared to $446,000 for NMP.Assuming an equal rate of ischemic cholangiopathy with NRP and NMP, the cost of NMP is $118,750 greater than the cost of NRP for all rates of ischemic cholangiopathy (Figure 2).Conclusions: Ischemic cholangiopathy has a significant impact on healthcare costs due to higher readmission rates, imaging studies, interventional procedures, and re-transplantation rates.Though there is data to suggest that both NRP and NMP reduce ischemic cholangiopathy, the cost of NRP is significantly less regardless of the rate of ischemic cholangiopathy.Determining which perfusion modality is most effective in reducing ischemic cholangiopathy in liver allografts from DCD donors could aid in optimizing utilization and cost-effectiveness of these emerging technologies.