Normothermic regional and ex-situ perfusion reduces Postreperfusion syndrome in donation after circulatory death liver transplantation: a retrospective comparative study

In controlled donation after circulatory death (DCD) liver transplantation, ischemia-reperfusion injury is linked to post-reperfusion syndrome (PRS), acute kidney injury (AKI), and early allograft dysfunction (EAD). Normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) are techniques that mitigate ischemic injury and associated complications. In this single centre retrospective study, we compared early transplant outcomes of DCD livers undergoing direct procurement (DP) and static cold storage (DCD-DP-SCS), NRP procurement with SCS (DCD-NRP-SCS), or DP with NMP (DCD-DP-NMP). Two hundred and thirty-eight DCD liver recipients were evaluated, comprising 59 DCD-DP-SCS, 101 DCD-NRP-SCS, and 78 DCD-DP-NMP. Overall, the PRS incidence was 19%. DCD-DP-SCS had higher incidence of PRS (37%; P<0.001), AKI stage≥2 (47%; P=0.033), and increased Model for Early Allograft Function (MEAF) score (p<0.001). In adjusted multivariate analysis, recipient age (OR 1.10, 95%CI 1.05-1.17; P<0.001), and normothermic perfusion (DCD-NRP-SCS OR 0.16, 95%CI 0.06-0.39; P<0.001; DCD-DP-NMP OR 0.38, 95%CI 0.15-0.91; P=0.032) were significant predictors of PRS, which itself was associated with worse 5-year transplant survival (graft survival non-censored-to-death; HR 2.9, 95%CI 1.3-6.7; P=0.012). Compared to static cold storage alone, use of either NRP or NMP significantly reduced the incidence of PRS and AKI with better early graft function.