Graft and patient outcomes after abdominal normothermic regional perfusion in liver transplantation

Donation after circulatory death (DCD) liver transplantation is currently limited by inferior outcomes compared with donation after brain death (DBD), predominantly due to ischaemia-reperfusion injury and biliary complications. Abdominal normothermic regional perfusion (aNRP) is an emerging graft-preservation technique that aims to improve graft viability, patient outcomes and reduce rate of complications in DCD liver transplantation. The aim of this review is to appraise the current literature on the utility of aNRP in liver transplantation surgery.

The PRISMA guidelines for systematic reviews were followed and relevant databases searched. Primary outcomes were graft and patient survival rates. Secondary outcomes were primary non-function, early allograft dysfunction, biliary complications including ischaemic cholangiopathy (IC)/ischaemic type biliary lesions (ITBL) and retransplantation rates. Risk-of-bias analysis was conducted. Narrative synthesis was performed due to marked heterogeneity in the included studies.

Fourteen studies (2014-2026) encompassing 1,278 transplanted aNRP liver grafts were included in this review. aNRP was associated with a reduction in IC/ITBL rates, lower rates of primary non-function and lower early allograft dysfunction compared with conventional retrieval (super rapid recovery followed by static cold storage). Graft loss and retransplantation rates were also lower in aNRP cohorts. Compared with DBD transplantation, aNRP outcomes were similar with near-zero rates of IC in both groups. No significant differences were also observed between aNRP and ex situ normothermic machine perfusion (NMP).

aNRP is associated with reductions in biliary complications, graft loss and retransplantation compared with conventional DCD retrieval, with outcomes comparable to DBD and ex situ NMP and offers a solution to expand the donor pool.