Normothermic Machine Perfusion, Patient-Centered Recovery, and Graft Survival After Donation-After-Circulatory-Death Liver Transplantation

BACKGROUND: Normothermic machine perfusion (NMP) may reduce preservation injury in donation-after-circulatory-death (DCD) liver transplantation, but its association with patient-centered recovery and longer-term graft survival remains uncertain. STUDY DESIGN: We retrospectively analyzed 306 consecutive adult DCD liver transplant recipients at a single center from January 2019 through December 2022, comparing NMP (n=95) with static cold storage (SCS; n=211). The primary endpoint was days alive and out of hospital at 365 days (DAOH365). Quasi-Poisson regression evaluated factors associated with DAOH365, and Cox regression evaluated graft survival. Propensity-matched and calendar-year sensitivity analyses assessed measured confounding. RESULTS: Median DAOH365 was 357.0 (352.0, 360.0) days with NMP versus 353.0 (336.0, 359.0) with SCS (p<0.001), but preservation strategy was not independently associated with DAOH365 (adjusted rate ratio 1.02; p=0.331). NMP recipients had less early allograft dysfunction (35.8% vs 59.7%; p<0.001), ischemic cholangiopathy (4.2% vs 23.7%; p<0.001), and retransplantation within 2 years (0.0% vs 6.6%; p=0.007). Two-year patient survival did not differ significantly. NMP was associated with improved twoF-year graft survival (HR 2.9, 95% CI 1.23-6.87; p=0.015), an association maintained in propensity-matched and calendar-year sensitivity analyses. Adjusted total 1-year costs did not differ (p=0.512). CONCLUSIONS: In this single-center DCD cohort, NMP was associated with superior 2-year graft survival but not independently with DAOH365. These hypothesis-generating findings support multicenter prospective evaluation of NMP using both graft survival and patient-centered recovery endpoints.