How to Preserve Liver Grafts From Circulatory Death With Long Warm Ischemia? A Retrospective Italian Cohort Study With Normothermic Regional Perfusion and Hypothermic Oxygenated Perfusion

Abstract Background: Donation after circulatory death (DCD) in Italy, given its 20-min stand-off period, provides a unique bench-test for normothermic regional perfusion (NRP) and dual hypothermic oxygenated machine perfusion (D-HOPE). Methods: We coordinated a multicenter retrospective Italian cohort study with 44 controlled DCD donors, who underwent NRP, to present transplant characteristics and results. To rank our results according to the high donor risk, we matched and compared a subgroup of 37 controlled DCD livers, preserved with NRP and D-HOPE, with static-preserved controlled DCD transplants from an established European program. Results: In the Italian cohort, D-HOPE was used in 84% of cases, and the primary nonfunction rate was 5%. Compared to the matched comparator group, the NRP+D-HOPE-group showed a lower incidence of moderate and severe acute kidney injury (stage 2: 8% vs 27% and stage 3: 3% vs 27%, P=0.001). Ischemic cholangiopathy remained low (2-year proportion free: 97% vs 92%, P=0.317), despite the high-risk profile resulting from the longer donor warm ischemia in Italy (40 vs 18min, P<0.001). Conclusions: These data suggest that NRP and D-HOPE yield good results in DCD livers with prolonged warm ischemia.