Expanding Access to Liver Transplantation Through Cost-effective Normothermic Machine Liver Perfusion: An Organ Procurement Organization–based Model and Its Clinical Impact

BACKGROUND: The shortage of transplantable livers, especially from donation after circulatory death (DCD) donors, remains a major challenge. Normothermic machine liver perfusion (NMLP) can further evaluate and potentially rehabilitate marginal grafts, but high costs and logistical barriers restrict its adoption. METHODS: A nonprofit organ procurement organization (OPO) integrated NMLP into its infrastructure, creating a cost-effective, equitable model for liver graft evaluation. This article describes the OPO-based approach and reports transplant outcomes from 1 regional partner center between May 2022 and July 2025. RESULTS: OPO adoption of NMLP enabled efficient deployment, reduced graft turndowns, and expanded donor acceptance criteria. In 2024 alone, the OPO perfused 75 livers, of which 61 were DCD donors, and 60 were successfully transplanted. At 1 partner institution, 72 NMLP-supported transplants were performed (86.1% DCD), with excellent 1-y survival (94.6%). Severe ischemic cholangiopathy was rare (1.6%), and most biliary complications were managed endoscopically. High-acuity recipients-including Model for End-stage Liver Disease score of 40, dual-organ, and retransplant candidates-benefited. CONCLUSIONS: An OPO-based NMLP model is scalable, sustainable, and equitable. It increases utilization of DCD livers, expands donor and recipient criteria, and improves regional access to transplantation.