Use of Machine Perfusion in the United States Increases Organ Utilization and Improves DCD Graft Survival in Liver Transplantation

Abstract

Background. Adoption of machine perfusion (MP) technology has rapidly expanded in liver transplantation without real-world data on utilization and outcomes, which are critical to understand the appropriate application of MP technology. Methods. The Organ Procurement and Transplant Network/Standard Transplant Analysis and Research database was used to identify all deceased donor livers procured with intent for transplant between October 27, 2015 (date of first recorded MP) and June 30, 2023 (n = 67 795). Liver allografts were cohorted by donation after brain death (DBD; n = 59 957) or circulatory death (DCD; n = 7873) and analyzed by static cold storage (SCS) or MP preservation method. Donor demographics, organ utilization, and graft survival were evaluated. Results. By 2023, 12.5% of all livers and 37.2% of DCD livers underwent MP preservation (82.6% normothermic, 6.7% hypothermic, and 10.8% other/unknown). Compared with SCS, MP liver donors were older (DBD: 48 versus 40 y [P < 0.001]; DCD: 43 versus 38 y [P < 0.001]) with higher body mass index (DBD: 28.8 versus 26.9 kg/m2 [P < 0.001]; DCD: 27.7 versus 26.9 kg/m2 [P = 0.004]). Donor livers had similar levels of macrosteatosis (median 5%). Graft utilization was higher for MP than SCS after DBD (96.4% versus 93.0%, P < 0.001) and DCD (91.4% versus 70.3%, P < 0.001) donation. Graft survival was similar between MP and SCS livers from DBD donors (P = 0.516), whereas MP-preserved grafts had superior survival from DCD donors at 1 and 3 y posttransplant (P = 0.013 and 0.037). Patient survival was similar across all groups at 3 y (P = 0.322). Conclusions. The use of MP in liver transplantation increased rates of liver utilization and improved graft survival after DCD. Further monitoring of MP outcomes is required to understand long-term benefits.