Donation After Circulatory Death Donor Liver Transplantation for Hepatocellular Carcinoma in the United States

Hepatocellular carcinoma (HCC) candidates rely on expanded donor utilization to maintain timely access to liver transplantation. Donation after circulatory death (DCD) allografts represent an important resource, but early experience raised concerns regarding inferior graft and patient outcomes compared with donation after brain death (DBD) donors. This review summarizes contemporary outcomes of DCD liver transplantation in HCC recipients and highlights the evolving role of advanced perfusion technologies in optimizing DCD outcomes. Recent multicenter and meta-analytic data demonstrate comparable overall survival, graft survival, and recurrence-free survival between DCD and DBD grafts in appropriately selected HCC recipients. Advanced preservation strategies—including normothermic machine perfusion (NMP) and normothermic regional perfusion (NRP)—have improved DCD graft utilization and reduced ischemia-reperfusion injury and biliary complications. Emerging approaches such as hypothermic oxygenated machine perfusion (HOPE) and ischemia-free liver transplantation (IFLT) may further optimize outcomes and potentially reduce HCC recurrence. Modern DCD liver transplantation is a safe and effective option for HCC recipients, and machine perfusion has been central to improving outcomes and expanding transplant access.