Anji Wall

Background.: Abdominal normothermic regional perfusion (A-NRP) is postmortem perfusion of organs in the abdominal cavity and can be performed using multiple approaches, including femoral, intra-abdominal, and thoracic. Our program began with surgeons performing intra-abdominal cannulations with mechanical or balloon occlusion of the descending thoracic aorta for A-NRP procedures. Recently, we developed a novel technique using the descending thoracic aorta for arterial cannulation with right atrial venous drainage. Methods.: All A-NRP cases performed by Regional Perfusion Services from July 1, 2024, to June 30, 2025, were retrospectively reviewed. Intraoperative parameters were collected for comparison. Results.: During the study period, 28 intra-abdominal normothermic regional perfusion (IA-NRP) cannulations and 47 descending thoracic normothermic regional perfusion (DT-NRP) cannulations were performed by 16 surgeons. Median cannulation time was shorter in the DT-NRP cohort (8.5 versus 10.0 min; P = 0.016). Median time on NRP was shorter in the IA-NRP cohort (61.5 versus 91.0 min; P = 0.006). The median decrease in lactate was larger in the DT-NRP cohort (2.9 versus 2.3 mmol/dL; P = 0.024). The median number of transfusions used was higher in the IA-NRP cohort (3.0 versus 0.0; P < 0.001). The learning curves show a quicker descent in time and a lower nadir for the DT-NRP cases, indicating this technique may have a quicker learning curve and be a more efficient approach to cannulation. Conclusions.: DT-NRP cannulation can be implemented for A-NRP with a quick learning curve, providing an additional cannulation option to the IA-NRP approach.

Introduction: Donation after circulatory death (DCD) graft use has become a standard practice globally to increase access to liver transplantation (LT). Machine preservation strategies have been widely adopted to improve graft quality, mitigate ischemia-reperfusion injury, expand organ utilization and enable organ viability assessment. However, the various approaches to MP have never been directly compared, particularly in the DCD cohort which might experience the greatest benefit. Methods: All cases of adult DCD-LT 2014-2024 preserved MP were collected from centers in Italy, The Netherlands, Switzerland, UK, and USA. DCD grafts preserved with cold storage (SCS) alone from previously established DCD-benchmarking cohorts served as comparators. Core Outcome Sets methodology was employed for standardized outcome analysis, comparing the impact of MP technologies in DCD grafts within established “benchmark” criteria to those with extended risk factors outside benchmarks. Results: Data were collected for 1538 perfused DCD-LT from >30 transplant centers; 995 (65%) were outside-benchmark criteria. Nearly half received NRP alone or combined with ex-situ perfusion (49%). Inside benchmark, nonanastomotic biliary strictures (NAS) were equally common in upfront NMP (14%) and back-to-base (B-t-B) NMP (14%). NRP (1%) and NRP+HOPE (2%) were protective ( P P 2 =0.201, Marginal=0.187). Similar trends were observed regarding actuarial 1-year GS. Conclusions and Relevance: Machine preservation strategies were associated with differences in outcomes in DCD LT and with lower observed NAS incidence and favorable adjusted survival estimates in DCD LT. NMP-based preservation was not associated with statistically significant reductions in NAS compared with benchmark SCS cohorts.

Normothermic Regional Perfusion (NRP) is being used to expand the utilization of organs from donation after circulatory death (DCD) donors and improve transplant outcomes (Bekki et al. 2023; Wall e...

Thoracoabdominal normothermic regional perfusion in donation after circulatory death: variation in practice and the need for shared standards, transparency, and ethical safeguards

Moving the needle on donation after circulatory death procedures

Acanthamoeba spp. was determined to be the cause of illness after an adult liver transplant recipient died from rapidly progressive encephalitis. Upon autopsy, amebae were identified in multiple organs, including the transplanted liver. The donor had history of kidney transplantation and died of encephalitis presumed to be due to toxoplasmosis. Acanthamoeba was identified in donor brain tissue by indirect immunofluorescence assay. Clinicians assessing prospective solid organ donors with encephalitis should consider Acanthamoeba infection.

Normothermic regional perfusion (NRP) adoption for donation after circulatory death (DCD) liver transplantation in the US has been growing, but there remains a higher rate of non-utilization of NRP DCD liver grafts as compared to donation after brain death liver grafts. Six transplant centers and one organ procurement organization (OPO) with substantial NRP liver procurement experience performed retrospective reviews of all NRP procurement attempts from September 1, 2021 until March 1, 2024, identifying opportunities for utilization. Five of the 6 transplant centers had prospectively collected data on all accepted livers with NRP intent. The transplant center intention to utilize DCD donors included 329 livers accepted for transplantation prior to withdrawal, 252 (76.6%) potential donors expired within the hospital timeframe for donation, and 168 (66.7%) livers were transplanted. Fifty-seven opportunities for utilization were identified by transplant centers plus 11 from the OPO: most were due to exceeding a functional warm ischemic time limit (n=26), other reasons (n=17) and functional assessment (n=16). The lessons learned by centers in this study provide guidance for newer NRP centers and for OPOs in identifying opportunities for utilization of NRP DCD grafts that have historically been declined. Export