Normothermic Machine Perfusion vs. Static Cold Storage for <scp>DBD</scp> Liver Transplantation in High‐ <scp>MELD</scp> Recipients: A Single‐Center Retrospective Study

BACKGROUND AND PURPOSE: While normothermic machine perfusion (NMP) has benefits over static cold storage (SCS), its efficacy in high-acuity recipients with high Model for End-Stage Liver Disease (MELD) scores, particularly using a back-to-base application model, is not well established. We aimed to compare short-term outcomes between NMP and SCS in this cohort. METHODS: This retrospective cohort study analyzed 215 adult recipients with a laboratory MELD score ≥ 25 who underwent isolated liver transplantation from donation after brain death (DBD) donors between July 2022 and June 2024. Patients were divided into SCS (n = 137; median MELD, 35) and NMP (n = 78; median MELD, 36) groups. Outcomes were compared using multivariable regression analyses. RESULTS: NMP was associated with higher daytime surgery rates (88.5% vs. 23.4%) and lower peak alanine aminotransferase levels (median 298 vs. 653 IU/L). However, no significant differences were found in blood loss, early allograft dysfunction, acute kidney injury, comprehensive complication index, hospital stay, or 90-day graft survival. CONCLUSIONS: In high-MELD recipients of DBD grafts, a predominantly back-to-base NMP approach did not improve major short-term clinical outcomes compared to SCS. Benefits of NMP appear to be highly context-dependent across three axes-graft type, application model (upfront vs. back-to-base), and recipient acuity.