Revisiting Simultaneous Liver and Kidney Transplantation from Donors After Circulatory Death in the Era of Machine Perfusion Technologies

OBJECTIVE: To evaluate national trends and clinical outcomes of donation after circulatory death (DCD) simultaneous liver-kidney transplantation (SLKT) in the US, particularly in the modern era following adoption of machine perfusion (MP) and normothermic regional perfusion (NRP). BACKGROUND: Utilization of DCD donors for liver transplantation has increased substantially in the US, and MP and NRP were reported to reduce complications, including reperfusion syndrome and early allograft dysfunction. However, national trends and outcomes of DCD-SLKT in the contemporary era of organ perfusion have not been characterized. METHODS: Using UNOS STAR files, we analyzed 10.687 adult primary SLKT performed between 2000 and 2025. Outcomes of DCD and donation after brain death (DBD) SLKT during 2020-2025 were compared using propensity score matching (PSM) to adjust for donor and recipient characteristics. Kaplan-Meier methods were used to assess graft/patient survival. RESULTS: The utilization of DCD-SLKT increased markedly after 2018, accounting for 29.3% of all SLKT cases in 2024. In 2024, liver MP, kidney MP, and NRP were used in 58.1%, 82.9%, and 40.1% of DCD-SLKT cases. Before matching, recipients in the DBD-SLKT group more frequently required dialysis at transplantation (69.1% vs 54.2%) and were hospitalized preoperatively (51.0% vs 17.2%), and had higher MELD scores (30 vs 23) during 2020-2025. Median follow-up was shorter in DCD-SLKT (706 vs 364 days), reflecting the more recent adoption of DCD transplantation. Liver graft/patient survival were comparable between DCD- and DBD-SLKT regardless of PSM. CONCLUSIONS: Utilization of DCD donors for SLKT has increased substantially in parallel with the expanding use of MP and NRP, with graft/patient outcomes comparable to those of DBD-SLKT regardless of PSM. However, DBD-SLKT recipients had higher baseline preoperative risk. These support broader adoption of DCD donors for SLKT in appropriately selected recipients.