Revisiting Futility: Normothermic Perfusion Improves Outcomes Across all UK DCD Risk Strata

Donation after circulatory death (DCD) liver transplantation is increasingly supported by routine use of normothermic machine perfusion (NMP), yet established risk scores, including the UK DCD score, predate widespread NMP adoption. We conducted a retrospective single-center cohort study of adult DCD liver transplants at Mayo Clinic Arizona from January 2019 through December 2024 (n = 586), comparing outcomes of NMP versus static cold storage (SCS) across UK DCD low-, high-, and futile-risk strata. Primary outcomes were early allograft dysfunction (EAD), ischemic cholangiopathy (IC), and graft and patient survival censored at two years. Of 586 transplants, 375 were preserved with NMP and 211 with SCS. Despite older donor age and longer warm ischemia times in the NMP cohort, NMP was associated with lower rates of EAD and IC across all strata. Two-year graft survival was higher with NMP than SCS (91% vs. 80%; p<0.001), and two-year patient survival was 96% versus 89% (p = 0.002). The graft and patient survival advantage was most pronounced in the high-risk (graft survival p = 0.004; patient survival p = 0.02) and futile strata (graft survival p = 0.01; patient survival p = 0.01), whereas graft survival was similar between preservation methods in the low-risk group. These findings support the use of the UK DCD score as a triage tool to guide NMP allocation, with the greatest benefit observed in high-risk and futile grafts for whom NMP should be considered essential rather than optional.