Abdominal normothermic regional perfusion in controlled DCD liver transplantation: outcomes and risk factors for graft loss.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through 12/31/2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59y [interquartile range 49-67y]. Adjusted risks estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, P<0.001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, P<0.001), graft loss (HR 0.371, 95% CI 0.267-0.516, P<0.001), and patient death (HR 0.540, 95% CI 0.373-0.781, P=0.001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, P=0.021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, P<0.001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.