Advanced perfusion techniques eliminate outcome gaps between DCD and DBD liver transplantation

Purpose: To evaluate the impact of advanced perfusion techniques in donation after circulatory death (DCD) liver transplantation (LT) compared to donation after brain death (DBD) on graft and patient outcomes.
Methods: Using the OPTN/STAR database, we identified adult deceased donor LT performed since FDA approval of normothermic machine perfusion (NMP) (2021-2025). DBD LT were compared to DCD LT stratified by procurement and preservation techniques: normothermic regional perfusion (NRP), standard rapid recovery (SRR) with NMP (DCD+NMP), combined NRP and NMP (DCD+NRP+NMP), and SRR with static cold storage (DCD+SCS). Propensity score matching was performed between DCD subgroups and DBD cohorts. Two-year graft survival was analyzed by Kaplan-Meier methods using the log-rank test. Cox proportional hazards models evaluated graft failure, with post-hoc pairwise comparisons derived from marginal contrasts and back-transformed to hazard ratios. Secondary outcomes were analyzed using logistic regression. P values <0.05 were deemed significant.
Results: Among 26,970 LT, 20,765 were DBD and 6205 were DCD (2695 DCD+NMP, 1176 DCD+NRP, 645 DCD+NRP+NMP, and 1689 DCD+SCS). Compared to DBD LT, the hazard of graft loss was higher following DCD+SCS (HR 1.78 [1.55-2.04]; p<0.001), but not statistically different for DCD+NMP (HR 1.16 [0.99-1.35]; p=0.063), DCD+NRP (HR 1.13 [0.88-1.44]; p=0.3), or DCD+NRP+NMP (HR 1.05 [0.73-1.50]; p=0.8. Figure 1). Propensity score matching similarly demonstrated inferior two-year graft survival following DCD+SCS (82% vs 88%; p<0.001. Figure2) but no difference between DBD and DCD grafts preserved with advanced perfusion techniques.
Among high-MELD (≥30) recipients, 2-year graft loss risk was not significantly different from DBD following DCD+NMP (HR 1.27 [0.81-1.98]; p=0.3) or DCD+NRP+NMP (HR 1.18 [0.44-3.18]; p=0.7) transplant; however, DCD+NRP had increased risk of graft loss (HR 1.89 [1.01-3.51]; p=0.046), with DCD+SCS demonstrated the highest risk (HR 2.48 [1.57-3.90]; p<0.001).
Secondary outcomes showed higher risk of ischemic cholangiopathy following DCD+SCS compared with DBD (HR 5.57 [3.20-9.75]; p<0.001). This was mitigated when DCD graft was procured and/or preserved with advanced perfusion methods, with DCD+ NRP showing lowest HR at 0.92 (all p>0.05 vs. DBD).
Conclusions: Advanced perfusion strategies mitigate risks associated with DCD liver grafts preserved with SCS, yielding outcomes comparable to DBD LT. However, among high-MELD recipients, outcomes following DCD grafts recovered using NRP were inferior to DBD grafts, suggesting that additional preservation strategies such as NMP may be required in this high-risk population. While SCS DCD grafts demonstrated a significant risk of ischemic cholangiopathy compared with DBD grafts, advanced perfusion, particularly NRP, may be protective by rapidly restoring organ perfusion during procurement and preserving peribiliary gland viability.