Comparative efficacy of advanced preservation strategies for donation after circulatory death liver grafts: A systematic review and network meta-analysis.
Ye Xin Koh, Yun Zhao, Darren Weiquan Chua et al.
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In 30 seconds
This systematic review and Bayesian network meta-analysis compared preservation strategies for donation after circulatory death (DCD) liver grafts across 19 comparative studies identified through June 2025. Compared with static cold storage (SCS), normothermic regional perfusion (NRP) was associated with better 1-year graft survival (hazard ratio, 0.67; 95% credible interval, 0.54-0.85) and patient survival (hazard ratio, 0.74; 95% credible interval, 0.55-0.94). Other strategies showed benefits for selected graft and biliary outcomes, but effects varied by modality and endpoint; NRP estimates are observational, not causal.
Key findings
- Compared with SCS, NRP was associated with improved 1-year graft survival (hazard ratio, 0.67; 95% credible interval, 0.54-0.85).
- Compared with SCS, NRP was associated with improved 1-year patient survival (hazard ratio, 0.74; 95% credible interval, 0.55-0.94).
- HOPE was associated with lower primary nonfunction and non-anastomotic biliary stricture; NMP was associated with lower early allograft dysfunction, non-anastomotic biliary stricture, and peak transaminases.
- Device-to-donor NMP was associated with lower early allograft dysfunction and non-anastomotic biliary stricture than SCS, and fewer strictures than back-to-base NMP.
Why it matters
DCD liver grafts are vulnerable to warm ischemic injury, and preservation choices may influence survival, graft function, and biliary complications. These comparative estimates suggest that advanced strategies do not have uniform effects across outcomes. Distinguishing modality-specific associations from causal effects is important when interpreting evidence and weighing preservation approaches.
What to keep in mind
The NRP evidence was entirely observational, so its comparative estimates do not establish causal treatment effects. Data for hybrid strategies were limited.