ECMO-Assisted In-Situ Normothermic Perfusion for Donation After Circulatory Determination of Death Kidney Transplantation: A Narrative Review

Kidney transplantation is a well-established treatment for patients with end-stage renal disease; however, graft availability is limited. To expand the donor pool, organs from expanded criteria donors and donors after circulatory determination of death (DCDD) are increasingly used. Normothermic in-situ regional perfusion (NRP) delivered using an extracorporeal membrane oxygenation device (ECMO) may be used, mitigating warm ischemia time and improving outcomes of DCDD grafts. NRP using ECMO (nECMO) during DCDD kidney transplantation achieves delayed graft function rates of 5.3% to 43.0%, primary non-function of 0.0% to 6.0%, and a 1-year mortality of 0.0% to 1.3%, closely mirroring DNDD outcomes. The survival rates of nECMO are comparable to DNDD or DCDD with the rapid recovery technique. Kidney discard rates are similar between nECMO and DNDD. Using nECMO in controlled and uncontrolled DCDD leads to better graft function and higher survival rates compared with standard DCDD transplantation. Outcomes are generally comparable to DNDD transplants. Early ECMO cannulation, even before death is declared, may minimize warm ischemia time and enhance graft function, although ethical concerns and strict protocols may hinder its routine use. This article aims to review available literature on ECMO implementation in DCDD kidney transplantation.