Decreased incidence of acute kidney injury following donation after circulatory death orthotopic liver transplantation using normothermic machine perfusion

Background Acute kidney injury (AKI) occurs in 40% to 70% of patients after orthotopic liver transplantation (OLT) and is associated with increased morbidity and mortality, longer intensive care and hospital stays, and higher costs. Normothermic machine perfusion (NMP) reduces ischemia-reperfusion injury, early allograft dysfunction, and ischemic biliary complications. However, its impact on postoperative liver transplant AKI remains unknown. Methods We conducted a single-center retrospective study of adult recipients of donation after circulatory death (DCD) liver transplants from January 2021 through December 2022. The primary outcome was postoperative AKI among recipients of NMP vs static cold storage (SCS) allografts, defining AKI using Kidney Disease: Improving Global Outcomes criteria. The Zhu modified Poisson regression with inverse probability weighting was used to estimate relative risk (RR). Results Among 195 DCD liver transplant recipients, 100 (51.3%) received SCS allografts; 95 (48.7%), NMP allografts. Baseline characteristics were similar. Overall, 38.5% developed AKI, with a lower incidence in the NMP group (RR, 0.64 [95% CI, 0.44–0.93]; P = .02). The NMP group had fewer blood transfusions (median: 10.0 vs 20.0; P < .001), a reduced incidence of postreperfusion syndrome (RR, 0.29 [95% CI, 0.16–0.53]; P < .001), and a reduced incidence of early allograft dysfunction (RR, 0.57 [95% CI, 0.42–0.77]; P < .001). No differences were observed in renal replacement therapy, hemodialysis at discharge, or chronic kidney disease at 90 days. Conclusions NMP was associated with a reduced incidence of postoperative AKI in DCD liver transplantation. These findings of improved postoperative renal outcomes support NMP for reducing morbidity and broader use of DCD allografts.