The Warm Revolution: A Meta-Analysis of DCD Versus DBD Liver Transplant Outcomes in the Normothermic Machine Perfusion Era

Introduction: Donation after circulatory death (DCD) livers have historically been associated with higher early allograft dysfunction rates, ischemic cholangiopathy, and graft loss when compared with donation after brain death (DBD) donors. Normothermic machine perfusion (NMP) emerged as a strategy to optimize graft preservation. This study aims to assess whether outcomes differ between DCD and DBD liver grafts preserved using NMP. Methods: We conducted a systematic review and meta-analysis of MEDLINE, Embase, and Cochrane databases, including randomized controlled trials (RCTs) and observational studies comparing DCD and DBD grafts undergoing NMP. Pooled analyses were performed using random-effects models with risk ratios (RR) and mean differences. Significance was set at p < 0.05. Results: Eighteen studies and 1578 livers were included, with 51.4% DCD grafts. Compared to DBD grafts, DCD grafts had significantly lower organ utilization (RR 0.84, I² = 62.1%, p < 0.001) but higher rates of biliary interventions (RR 2.48, I² = 0.0%, p = 0.008). No significant differences were observed in the incidence of non-anastomotic or anastomotic biliary strictures, post-reperfusion syndrome, early allograft dysfunction, primary non-function, acute kidney injury, ICU or hospital stay, hepatic laboratory parameters, or graft and patient survival at 1 year. Conclusion: DCD liver transplantation with NMP achieves outcomes comparable to DBD grafts across major clinical endpoints, including biliary complications, allograft function, and survival. However, these findings apply to a selected subgroup of DCD grafts that meet viability criteria during perfusion. Moreover, DCD grafts were more frequently subjected to biliary procedures without being associated with increased complication rates. Ultimately, DCD grafts had lower organ utilization rates than DBD, even in the setting of machine perfusion.