Propensity Score–Matched Comparison of Normothermic Machine Perfusion and Normothermic Regional Perfusion in Donation After Circulatory Death Liver Transplant

BACKGROUND: Normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) have rapidly expanded donation after circulatory death (DCD) liver transplant, but comparative real-world data are lacking. METHODS: Adult liver transplants performed in the advanced perfusion era (December 2021-June 2025) were analyzed via the Organ Procurement and Transplant Network/Standard Transplant Analysis and Research database. DCD grafts were stratified by advanced perfusion modality (DCD+NMP, DCD+NRP, or DCD+NRP+NMP) or static cold storage (DCD+SCS), and compared with donation after brain death (DBD) transplants. "Back-to-base" machine perfusion cases were excluded. Primary outcome was 2-y graft survival. RESULTS: Among 26 021 liver transplants, 20 765 were DBD and 5256 were DCD (2695 DCD+NMP, 861 DCD+NRP, 645 DCD+NRP+NMP, and 1055 DCD+SCS). Hazard of 2-y graft loss was not statistically different from DBD transplants for DCD+NMP (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.99-1.35; P = 0.069), DCD+NRP (HR, 1.14; 95% CI, 0.87-1.49; P = 0.3), and DCD+NRP+NMP (HR, 1.04; 95% CI, 0.73-1.49; P = 0.8) cohorts. DCD+SCS demonstrated increased hazard of 2-y graft loss (HR, 1.79; 95% CI, 1.52-2.10; P < 0.001). Propensity score matching to DBD cohorts revealed no difference in 2-y graft survival after DCD+NMP (P = 0.11), DCD+NRP (P = 0.12), or DCD+NRP+NMP (P = 0.6), with inferior graft survival after DCD+SCS (P < 0.001). Comparison of DCD+NMP and DCD+NRP by propensity score matching showed no difference in 2-y graft survival (P = 0.3). Hazard of ischemic cholangiopathy was increased over DBD liver transplants for DCD+SCS (HR, 5.51; 95% CI, 2.94-10.3; P < 0.001) and DCD+NMP (HR, 2.11; 95% CI, 1.02-4.23; P = 0.038) but not DCD+NRP (HR, 1.27; 95% CI, 0.29-4.02; P = 0.7) or DCD+NRP+NMP (HR, 1.04; 95% CI, 0.15-4.11; P > 0.9). CONCLUSIONS: Advanced perfusion with NMP and/or NRP in DCD liver transplant demonstrates superior graft survival compared with traditional SCS, with 2-y graft survival approaching DBD outcomes. Advanced perfusion should be routinely considered in DCD liver transplant.