Deceased Donor Liver Procurement and Preservation Techniques: What is Cost-effective? A Systematic Review

Machine perfusion (MP) strategies have altered the landscape of deceased donor liver procurement and preservation in recent years. Upfront costs for MP are significantly higher than those of conventional procurement/preservation techniques. We performed a systematic review to evaluate the cost-effectiveness of various MP strategies as alternatives to conventional liver procurement and preservation before liver transplantation (LT). A systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed for articles published up to February 2025, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Fourteen studies reported the cost-effectiveness of MP before LT, including hypothermic oxygenated liver perfusion (n = 4), normothermic machine perfusion (n = 8), and normothermic regional perfusion (n = 2). Inflation-adjusted costs per MP run varied: normothermic machine perfusion (US$11 455-35 766), hypothermic oxygenated liver perfusion (US$6489-12 686), and normothermic regional perfusion (US$9287; single study). Six studies analyzed cost-effectiveness using real-world cohorts. All but one study found MP to be cost-effective; 5 reported overall cost savings compared with conventional procurement and static cold storage. MP influenced costs across the entire LT pathway: pre-LT (lower waitlist healthcare costs, fewer procurement "dry runs," improved organ utilization) and post-LT (shorter intensive care unit/hospital stays, reduced allograft dysfunction, need for dialysis, cholangiopathy, and retransplantation). Three studies found cost-effective improvements in quality-adjusted life years with MP. Although direct and indirect MP costs varied and were inconsistently reported, all studies based on real-world data found MP to be at least cost-neutral. Initial MP costs were offset by savings in waitlist and postoperative costs. Real-world data on the cost-effectiveness of NRP remain limited. Future clinical studies should include cost-effectiveness analysis to support institutional and policy-level investment in MP technologies.