Network Meta-Analysis of Static Cold Storage Versus Dynamic Organ Preservation for Liver Transplantation

Donor organ scarcity and increasing use of extended-criteria donors have driven the development of dynamic preservation methods to improve outcomes following liver transplantation. Hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP), controlled oxygenated rewarming (COR), and ischemia-free liver transplantation (IFLT) are dynamic preservation methods that have been compared with traditional static cold storage (SCS). However, no randomized clinical trials (RCTs) have directly compared HMP with NMP. The aim of the present study is to conduct a network meta-analysis (NMA) of RCTs to compare the effects of available dynamic preservation strategies on clinical outcomes.

Electronic databases were systematically searched for RCTs evaluating dynamic preservation methods in human liver transplantation. Eligibility criteria included reporting of at least one of the following primary outcome measures: early allograft dysfunction (EAD), biliary complications, and graft survival. A random-effects Bayesian NMA with a non-informative prior was conducted.

Thirteen RCTs were included with a total of 1888 recipients and assessed 5 interventions. IFLT had the highest probability of being the best-ranked treatment for EAD and biliary complications, but these findings were based on a single RCT. HMP (7 RCTs) ranked higher than NMP (4 RCTs) across all primary outcomes, whereas NMP ranked higher than SCS for EAD and biliary complications. Subgroup analysis of extended criteria brain-dead donors was consistent with overall findings.

Dynamic preservation modalities were associated with improved outcomes compared with SCS. HMP ranked higher than NMP across the primary outcomes. However, these comparisons were predominantly indirect and do not establish superiority of HMP over NMP.