Center-Level Variability in Use of Normothermic Machine Perfusion and the Association With Recipient Insurance

The rapid implementation of normothermic machine perfusion (NMP), since the FDA-approved NMP devices, has resulted in a paradigm shift in the ability to use marginal livers and allow for daytime operations. A major rate-limiting factor is costs which could lead to disparities among recipients. We aim to evaluate center-level variability in utilization of NMP, and to determine whether recipient insurance type was associated with NMP.

We evaluated deceased donor liver transplants in high-volume NMP centers between January 2022 and December 2023, using the national registry. The primary outcome was whether the DDLT was performed using NMP. To explore center-level and factors associated with NMP, we evaluated variables related to donor quality and insurance. We fit multivariable logistic regression models to evaluate these factors.

Out of 142 liver transplant centers, 72 had ≥1 DDLT using NMP, and 28 were high-volume NMP centers. There was marked center-level variability in the proportion of donation after brain death (DCD) versus donation after brain death (DBD) allografts that underwent NMP. In logistic regression, liver allografts procured using NMP were more likely to occur during the nighttime (OR 1.26, p < 0.001), more likely to be used for DCD allografts (OR 13.2, p < 0.001), and less likely to occur in recipients insured by Medicaid, Medicare, or the Veterans Health Administration.

Our study demonstrates center-level variability in the use of NMP, and factors associated with these differences. Although the change in practice may help to increase DCD utilization, and shift the timing of transplants, the disparity based on insurance is alarming.