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BACKGROUND: In-situ normothermic regional perfusion (NRP) and ex-situ normothermic machine perfusion (NMP) aim to improve outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. METHODS: In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor centre were compared using propensity score matching (PSM). RESULTS: Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. Within the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (utilisation rates: 70% vs 85% [p=0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemic time (21 min after NRP vs 20 min after NMP; p=0.17), UK-DCD risk score (5 vs 5 points; p=0.38) and lab-MELD scores (12 vs 12 points; p=0.83). The incidence of non-anastomotic biliary strictures (1.5% vs 2.9%; p>0.99), early allograft dysfunction (20.6% vs 8.8%; p=0.13) and 30-day graft loss (4.4% vs 8.8%; p=0.40) were similar, although peak post-transplant AST levels were higher in the NRP cohort (872 vs 344 IU/l; p<0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (60.3% vs 20.6%; p<0.001). HCC-censored 2-year graft and patient survival were 91.5% vs 88.2% (p=0.52) and 97.9% vs 94.1% (p=0.25) after NRP and NMP, respectively. CONCLUSION: Both perfusion techniques achieved similar outcomes and appear to match benchmarks expected for DBD livers. This study may inform the design of a definitive trial.

Original publication




Journal article


Liver Transpl

Publication Date



Organ preservation, Outcome, procurement