Posttransplant Health–economic Impact of Normothermic Machine Perfusion (Back-to-base Model): Advancing Donation After Circulatory Death Liver Transplants With Improved Outcomes and Reduced Wait Times

Background. The widespread use of normothermic machine perfusion (NMP) has enabled greater utilization of donation after circulatory death (DCD) liver grafts for transplantation. Use of NMP can cost an additional $40 000–$100 000 The aim of our study was to see whether the use of NMP would lower postoperative costs after DCD liver transplantation (LT). Methods. Retrospective data of all DCD LTs performed at our center between August 19, 2022, and May 31, 2024, were analyzed. The OrganOx metra device, back-to-base, was used for NMP at our center. United Network for Organ Sharing data were used to present national DCD LT volumes and waitlist outcomes. Results. Sixty-seven NMP and 44 static cold storage transplants were performed. In the NMP group, donors were older (50 versus 45 y, P = 0.0260), were at increased risk (US donor risk index 2.43 versus 2.12, P = 0.006), incidence of early allograft dysfunction (42% versus 75%, P = 0.0008) and postreperfusion syndrome (25% versus 48%, P = 0.0239) was lower, and recipients had better native kidney function at 3 mo (estimated glomerular filtration rate 73 versus 62 mL/min/1.73 m 2 , P = 0.0205). Use of NMP did not decrease postoperative direct costs. On multivariate analysis, an additional 56 min of cold ischemic time and the presence of postreperfusion syndrome increased postoperative direct costs by $14 700 and $23 100, respectively. Conclusions. Use of NMP does not decrease postoperative direct costs after DCD LT. However, with the use of NMP, a greater number of DCD liver grafts can be used, from a broader range of donors, wait time to transplant can be reduced, and waitlist survival can be improved while improving relevant clinical outcomes. The overall cost savings achieved by transplanting patients quickly at low Model for End-stage Liver Disease scores and improving waitlist morbidity should be further explored.