Evaluating current efficiency of normothermic machine perfusion in donation after circulatory death liver transplantation amidst widespread utilization

Normothermic machine perfusion (NMP) has shown promise in improving outcomes for donation after circulatory death (DCD) liver transplants, but published data is dominated by clinical and single center trials. As US transplantation community gains widespread experience with NMP, it is imperative to continuously evaluated NMP efficiency over static cold storage (SCS). We conducted a retrospective review of DCD liver transplants from 2016 to 2023, dividing data into two eras: pre-2023 and 2023. Demographic data revealed the change in donor and recipient selection over these two time periods. Cox proportional hazards models on propensity score data analyzed the current benefit of NMP over SCS. In the later era, grafts selected for NMP were increased risk donors with increased agonal time. Despite using high-risk grafts in the later era, NMP still had significantly improved graft survival and there was a lower incidence of diffuse cholangiopathy but not significantly improved patient survival over SCS. As transplant programs’ NMP utilization increases by expanding the selection criteria and increasing the agonal time of donors, NMP still has significantly better graft survival than SCS. Continued evaluation of NMP is essential to determine its efficiency over SCS and a first step in accurate cost-effectiveness studies.