Improved Outcomes with Hypothermic Machine Perfusion in Donation after Circulatory Death Liver Transplantation

Donation after circulatory death (DCD) allografts were not widely used in liver transplantation (LT) due to higher rates of biliary complications and retransplantation. Although European trials have shown improvement in early allograft function and biliary complications with hypothermic-oxygenated machine perfusion (HMP-O2) compared with traditional static cold storage (SCS) on ice, no US clinical series have demonstrated a benefit.

All DCD LTs performed at a single center from April 6, 2015, to December 24, 2024, were evaluated. DCD-HMP-O2 transplants were performed under a clinical trial (NCT03484455 and NCT05574361). Six-month outcomes were compared between those preserved with SCS (n = 47) vs HMP-O2 (n = 62).

Among 109 DCD LT recipients, the median age was 61 years, 29.4% were female, with a BMI of 29.6 kg/m 2 and a Model for End-Stage Liver Disease score of 16. DCD-HMP-O2 donors were older (51 vs 37 years, p < 0.001), had longer functional warm ischemia time (23 vs 18 minutes, p < 0.001), higher UK-DCD risk scores (8 vs 3, p < 0.001), and longer preservation times (9.1 vs 4.7 hours, p < 0.001). DCD-HMP-O2 recipients had lower incidence of primary nonfunction (0.0% vs 6.4%, p = 0.04), nonanastomotic biliary strictures (1.6% vs 14.9%, p = 0.008), and ischemic cholangiopathy (1.6% vs 10.6%, p = 0.04) compared with DCD-SCS recipients. After adjustment, HMP-O2 use was associated with 97% lower odds of ischemic cholangiopathy (adjusted odds ratio 0.03, 95% CI 0.01 to 0.71, p = 0.03) compared with SCS.

In this first US study of HMP-O2 use in DCD LT, HMP-O2 decreased primary nonfunction and biliary complications compared with SCS, despite the use of higher risk DCD allografts. With the exponential rise in DCD use, HMP-O2 can improve clinical outcomes for these recipients.