Embracing Liver Transplantation From Donation After Circulatory Death in the United States in the Era of Perfusion Technology

Background. Utilization rates of potential deceased donors for liver transplantation has declined following the implementation of the acuity circles system in 2020. Since then, ex situ machine perfusion (es-MP) and normothermic regional perfusion (NRP) have been introduced in the United States. Methods. Liver graft utilization rates were analyzed using the US national registry data from 2022 to 2024. The associations of es-MP and NRP practices with donation after circulatory death (DCD) utilization rates among organ procurement organizations (OPOs) and transplant center volume were evaluated. Results. DCD donor utilization significantly increased from 21.5% in 2022 to 42.5% in 2024 ( P < 0.001). Utilization of extended criteria donors (ECDs), including DCD donors aged ≥60 y or with a body mass index ≥40 kg/m 2 , also rose substantially, from 7.1% in 2022 to 33.2% in 2024 ( P < 0.001). At the transplant center level, a significant correlation was found between the increase in transplant volume and both the es-MP use ( r = 0.29; P = 0.01) and ECD utilization ( r = 0.26; P = 0.02). At the OPO level, a significant association was observed between the increase in DCD utilization rate and NRP use ( r = 0.29; P = 0.03). Conclusions. DCD liver utilization has significantly increased, with a notable rise in the utilization of ECDs, which may be driven by new technologies such as es-MP and NRP. While es-MP at the center level use may increase transplant volume, NRP use at the OPO level appears to significantly improve DCD liver utilization.