Objective: To determine whether normothermic machine perfusion (NMP) mitigates the historical survival disadvantage of donation after circulatory death (DCD) liver transplantation compared with donation after brain death (DBD) livers. Summary Background Data: NMP has improved outcomes in DCD LT compared with static cold storage (SCS), but whether it eliminates the historical disparity relative to DBD transplantation remains uncertain. Methods: We performed a retrospective cohort study of adult LT at a high-volume US center between 2019 and 2024. Outcomes of DCD-NMP grafts were compared with DCD-SCS, DBD-SCS, and DBD-NMP grafts. Primary outcomes were 1-year graft and patient survival. Secondary outcomes included early allograft dysfunction (EAD), hepatic artery thrombosis (HAT), primary nonfunction (PNF), biliary anastomotic strictures (BAS), and ischemic cholangiopathy (IC). Results: Among 1338 liver transplants (DBD-SCS n=527; DBD-NMP n=142; DCD-SCS n=255; DCD-NMP n=414), DCD-NMP grafts had a significantly higher donor risk profile ( P <0.001) yet demonstrated survival comparable to DBD transplantation. One-year graft survival was 94% for DCD-NMP versus 93% for DBD grafts and 86% for DCD-SCS, and 1-year patient survival was 98% for DCD-NMP versus 94% to 95% for DBD grafts and 93% for DCD-SCS. In adjusted models, DCD-SCS was associated with increased hazards of graft loss (adjusted hazard ratio: 2.48; P <0.001) and death (adjusted hazard ratio: 2.39; P =0.004), whereas DBD groups did not differ from DCD-NMP. Incidence of EAD was lower with DCD-NMP (21.7%) than DCD-SCS (50.2%) and similar to DBD grafts (21.1%–26.4%); HAT and PNF were rare (≤1.3%). At 1 year, BAS occurred in 36% of DCD grafts versus 17% to 23% of DBD grafts. IC occurred in 7.7% of DCD-NMP compared with 22% of DCD-SCS and ≤1.5% of DBD grafts. Retransplantation due to IC was infrequent overall (1.3%), but more common in DCD-SCS (4.7%) than DCD-NMP (1.0%) and DBD grafts (≤0.4%). Conclusions: NMP enables safe utilization of DCD liver allografts and achieves graft and patient survival comparable to DBD LT, mitigating the historical disadvantage of DCD grafts. These findings support routine integration of NMP into clinical practice and efforts to standardize its implementation.

The global shortage of transplantable donor livers increases reliance on marginal grafts, creating an urgent need for workflow-compatible assessment during normothermic machine perfusion. However, current biochemical evaluation remains constrained by intermittent perfusate sampling, low temporal resolution and limited cholangiobiliary context. Here we report a clinically deployed dual-compartment biochemical monitoring (DCBM) platform for human liver perfusion. The system integrates dual-channel microfluidics, multiplexed electrochemical sensing, bile-compatible antifouling interfaces and wireless data transmission to enable automated in-line measurement of pH, lactate and glucose in both perfusate and bile. In seven human donor livers, the DCBM platform shows strong agreement with standard laboratory assays while resolving transient biochemical excursions not captured by scheduled hourly sampling, including bile lactate elevations associated with subsequent adverse perfusion trends in selected cases. Continuous dual-compartment measurements further enable an exploratory outcome-anchored framework linked to post-transplant clinical course. This platform establishes a clinically deployed architecture for dual-compartment biochemical monitoring and provides an initial translational bridge from continuous sensing to viability-associated graft assessment during ex situ liver perfusion.

PURPOSE OF REVIEW:Living donor transplantation is the optimal treatment for end-stage renal disease and end-stage liver disease. For the recipient, the benefits of living donation include improved duration of graft survival compared to deceased donation and avoidance of lengthy waiting time and risks of dialysis. For transplant centers, a robust living donor program results in consistent transplant case volumes, daytime cases and a decreased reliance on potentially unfavorable allocation policy changes. Transplant programs require a playbook of actionable initiatives based on consensus best practices and peer-reviewed data to optimize opportunities to increase living donor evaluation and surgery within current legal and policy frameworks. RELEVANT FINDINGS:Strategies to increase center living donor volume include utilization of culturally competent transplant education and outreach, development of living donor champion programs, wider utilization of financial assistance programs available to living donors, increased enrollment in paired donor exchange services and adaptation of modern evidence-based selection and evaluation criteria. SUMMARY:Understanding the current landscape of living donor transplantation and exploring areas of innovation is imperative to a center's ability to continue to serve the full spectrum of patients with end stage organ disease to the best of our collective ability.

Transplant Oncology is an evolving field. While liver transplantation was once contraindicated in patients with cancer, the safety and survival benefit of utilizing transplantation as a curative-intent treatment for primary and metastatic hepatic malignancies has been demonstrated. Currently, liver transplantation is offered to selected patients with hepatocellular carcinoma, perihilar and intrahepatic cholangiocarcinoma, colorectal cancer with isolated liver metastases, and neuroendocrine tumors with isolated liver metastases. We will cover the current inclusion and exclusion criteria and clinical and pathologic factors of each oncologic indication, and future directions in liver transplant oncology. Successful oncologic outcomes for liver transplantation hinge on careful selection of patients. The evolving role of immunotherapy and targeted tumor therapies have allowed for previously transplant-ineligible patients to be considered for curative-intent transplantation, rather than palliative-intent care. Increasing our knowledge through coordinated multi-institutional studies of each disease process with liver transplantation will be imperative to continue to safely broaden the indications and offer hope to these complex groups of patients. Reframing recipients with oncologic indications for transplant should occur carefully and with attention to rigorous analysis of clinical outcomes. The objective of this article is to situate the evolving treatments for hepatic malignancies within the expanding scope of transplant oncology.

Key Points. Health care utilization rates in elderly kidney transplant were no different between the high kidney donor profile index and low kidney donor profile index group. Number of readmissions and surgical interventions in elderly kidney transplant was no different between the high kidney donor profile index and low kidney donor profile index group. Death censored graft loss was higher in the high kidney donor profile index group, whereas the patient survival was no different between the high kidney donor profile index and low kidney donor profile index groups. Background. High kidney donor profile index (KDPI) kidneys (KDPI >85%) are often associated with increased risks of post-kidney transplant (KT) complications and greater health care utilization (HCU), particularly in elderly recipients with multiple comorbidities. These concerns frequently lead to underutilization of high KDPI kidneys in older transplant candidates, thereby limiting their access to transplantation despite potential clinical benefits. The aim of this study was to compare post-KT HCU between elderly recipients of high versus low KDPI deceased donor kidneys. The primary outcome included differences in hospital readmissions, surgical interventions, and outpatient service use at multiple post-transplant time points. Secondary outcome included graft function, graft survival, and patient survival. Methods. A retrospective analysis of elderly solitary KT recipients (age ≥65 years) between January 1, 2011, and December 31, 2020. Patients were stratified into high KDPI (>85%, n=160) and low KDPI (≤85%, n=453) groups. We assessed inpatient and outpatient HCU, including readmissions at 30, 90, and 365 days post-transplant, surgical interventions, and outpatient visits (emergency department, transplant clinic, endocrine clinic, and ambulatory infusion units). Results. There were no statistically significant differences between high and low KDPI groups in rates of hospital readmissions, surgical interventions, or outpatient visits (all P > 0.05). Delayed graft function rates were also similar (P = 0.61). The low KDPI group had significantly higher eGFR at 4 months, 1, 2, and 3 years post-transplant (all P < 0.001). However, days alive and out of the hospital within 90 and 365 days post-transplant were comparable between the groups (all P > 0.05). Overall patient survival was similar (P = 0.08), although death-censored graft loss was significantly higher in the high KDPI group (P = 0.001). Conclusions. Among elderly KT recipients, high KDPI kidney recipients had comparable post-transplant HCU and overall survival with those receiving low KDPI kidneys, despite lower long-term graft function. These findings suggest that high KDPI kidneys remain a viable option for older patients, offering timely access to transplantation.

Donation after circulatory death (DCD) liver transplantation is increasingly supported by routine use of normothermic machine perfusion (NMP), yet established risk scores, including the UK DCD score, predate widespread NMP adoption. We conducted a retrospective single-center cohort study of adult DCD liver transplants at Mayo Clinic Arizona from January 2019 through December 2024 (n = 586), comparing outcomes of NMP versus static cold storage (SCS) across UK DCD low-, high-, and futile-risk strata. Primary outcomes were early allograft dysfunction (EAD), ischemic cholangiopathy (IC), and graft and patient survival censored at two years. Of 586 transplants, 375 were preserved with NMP and 211 with SCS. Despite older donor age and longer warm ischemia times in the NMP cohort, NMP was associated with lower rates of EAD and IC across all strata. Two-year graft survival was higher with NMP than SCS (91% vs. 80%; p<0.001), and two-year patient survival was 96% versus 89% (p = 0.002). The graft and patient survival advantage was most pronounced in the high-risk (graft survival p = 0.004; patient survival p = 0.02) and futile strata (graft survival p = 0.01; patient survival p = 0.01), whereas graft survival was similar between preservation methods in the low-risk group. These findings support the use of the UK DCD score as a triage tool to guide NMP allocation, with the greatest benefit observed in high-risk and futile grafts for whom NMP should be considered essential rather than optional.

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<0.001). Outside benchmark, NAS was least frequent in the NRP+HOPE (2%), and NRP-alone (4%) group, and most common in the B-t-B NMP (18%, P<0.001) cohort. Upfront NMP demonstrated a lower observed NAS incidence than B-to-B NMP (9% vs. 18%). NRP, NRP+HOPE, and HOPE demonstrated a pattern of convergence in outcomes between inside- and outside-benchmark grafts in multivariable analyses. Binary logistic mixed-effects modelling demonstrated NAS-reduction with NRP+HOPE (OR=0.201, 95% CI= 0.075-0.569) and NRP alone (OR=0.281, 0.105-0.569). Other preservation modalities did not differ, including upfront NMP, which was similar to B-t-B NMP and SCS. Increasing donor age was detrimental to NAS rates (OR=1.02, 95% CI= 1.004-1.036). Donor and preservation factors demonstrated a 19% impact on NAS versus recipient factors (labMELD, age, BMI), which contributed with only 3% (Conditional Pseudo-R2=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.

BACKGROUND:With increasing use of donation after circulatory death (DCD) donor grafts, the need for accurate risk-stratification tools in liver transplantation has become critical. Machine perfusion has been shown to improve both graft and patient survival. However, existing prediction models were developed in the static cold storage (SCS) era and their accuracy when using machine perfusion remains unknown. Our study aims to study if current scoring systems can predict graft and patient survival for DCD livers preserved using normothermic machine perfusion (NMP). METHODS:This was a retrospective study of patient and graft survival in a two-center U.S. DCD NMP cohort (n = 532) between January 2022 and December 2024. Predicted graft and patient survival rates were obtained from established risk scoring systems, including the United Kingdom DCD risk score (UK-DCD), Early Allograft Dysfunction (EAD) Olthoff score, Liver Graft Assessment Following Transplantation (L-GrAFT7) score, Donor Risk Index (DRI), Balance of Risk (BAR) score, and Survival Outcomes Following Liver Transplant (SOFT) score. Model discrimination was assessed using receiver operating characteristic (ROC) curves (C-statistics). Survival outcomes across risk strata were estimated and compared using Kaplan-Meier (KM) analysis. RESULTS:Across scoring systems, predicted survival consistently underestimated actual graft and patient survival in the NMP DCD cohort. The DRI, SOFT, EAD and L-GrAFT7 did not demonstrate predictive value. UK-DCD predicted ≤85% and <40% 1-year graft survival for its high-risk and "futile" groups, whereas observed rates were 93.7% and 86.8%. BAR low-risk predicted >60% 5-year survival but 94.2% was observed; the high-risk group predicted <60% and observed was 53.3%. Despite underestimations and generally poor C-statistics, in KM stratification, high-risk groups still showed statistical differences in the UK-DCD categories (p = 0.007), and in SOFT score groups (p < 0.001). No statistical difference was seen in BAR (p = 0.36), DRI (p = 0.36), EAD (p = 0.12), or L-GrAFT7 (p = 0.75). CONCLUSION:Existing liver transplant risk scores show limited predictive value for donor-related risk factors in the NMP era, whereas recipient-related factors remain somewhat predictive, despite overestimating risk. Early allograft dysfunction metrics were not reliable predictors of short or long-term outcomes. Future risk models should integrate machine-perfusion parameters and refined donor variables to reflect outcomes more accurately in contemporary DCD liver transplantation.

Cirrhosis induces a hyperdynamic circulatory state with portal hypertension, leading to chronic right ventricular volume overload and tricuspid annular dilation, often resulting in functional tricuspid regurgitation (TR). Severe TR exacerbates hepatic congestion and significantly increases perioperative risk during liver transplantation. We present a 52-year-old woman with decompensated cirrhosis secondary to alcohol use who was initially deemed ineligible for liver transplantation due to severe TR. Despite aggressive medical optimization, her TR persisted, and surgical repair was contraindicated due to prohibitive operative risk. The patient subsequently underwent successful transcatheter tricuspid valve edge-to-edge repair, reducing TR from severe to mild. This intervention enabled her to qualify for successful simultaneous liver-kidney transplantation with favorable postoperative graft function. This case highlights the potential role of transcatheter tricuspid valve edge-to-edge repair as a bridge to transplantation in patients with decompensated cirrhosis and severe TR when conventional surgical approaches have an excessive risk. Multidisciplinary collaboration is critical, and further studies are warranted to define outcomes and establish selection criteria in this high-risk population.

Limited information on the business practices of liver transplant (LT) centers worldwide has been published. Characterizing this data could help identify best practices as well as opportunities for improvement. As such, the International Liver Transplant Society (ILTS) Business Practice Committee conducted a global online survey of LT centers, which was sent to the ILTS membership. Questions focused on 5 main domains: transplant practice and volumes, workforce, finances, quality assessment and performance improvement, and overall program function. Data was compared across program geographic regions and transplant volume. A total of 89 discrete centers were represented, of which 76.4% were academic/university-affiliated, and about one-third each were from Europe (36.0%) and North America (31.5%). The top 3 problems programs reported were finances/funding (60.7%), adequate program support/guidance (48.3%), and transplant volumes (43.8%). In all, 59.6% of respondents felt their salary was undercompensated, consistent across geographic regions. In addition, 69.7% felt their center was not adequately funded to meet program goals, with programs in Europe (N=28/32, 87.5%) and Oceania (N=2/3, 66.7%) most impacted. Transplant surgeon retainment was noted as more difficult for lower volume programs (<50 liver transplants/year, N=13/31). Nearly half (42.7%) of all programs felt under-resourced to provide high-quality care, and the majority (80.9%) felt there was room for growth and improvement under their current model. While international concerns varied widely among LT centers, inadequate salary and center funding, low transplant and referral volumes, and staff retainment were persistent themes. Focusing on adopting region-specific best practices and developing transplant systems of care that focus on these elements is critical to provide optimal care to LT patients worldwide.

Donation after circulatory death (DCD) livers increasingly use machine perfusion (MP). This study evaluates MP's impact on older DCD livers based on data from the United Network for Data Sharing, covering all first adult DCD liver transplants (2016-2025). The cohort, divided into pre-MP and MP eras (separated by the FDA approval of the first normothermic MP platform in 2021), showed accelerated growth in DCD liver transplants during the MP era. Donors ≥60 rose 7.8-fold, including donors ≥70 (a USA first). By 2025, DCD livers accounted for 43.2%, with 61.35% from donors ≥50. Normothermic regional perfusion (NRP) (3.0%-16.5%), NMP (2.1%-38.9%), and sequential NRP-NMP (0.1%-10.7%) increased significantly (p < 0.001). The MP era was associated with a decrease in median waitlist time from 112 to 62 days (p < 0.001). Early graft survival was similar across ages. For ages 50-59, 1- and 3-year survivals were 87.9%/78.4% pre-MP and 90.1%/78.8% in the MP era. For 60-69, survival was 85.0%/80.6% pre-MP and 90.0%/71.3% in the MP era. DCD LTs for ≥70 were limited to the MP era with 87.8% 1-year survival. Multivariable Cox regression showed that static cold storage (HR = 1.29), donor age 50-69 versus 18-49, and recipient age (HR = 1.01) increased the risk of graft loss after adjustment. MP is associated with an increased number of older DCD liver transplants and acceptable early graft survival.

Normothermic machine perfusion (NMP) enables preservation and functional assessment of liver allografts, improving outcomes, particularly in marginal organs. However, the TransMedics Organ Care System (OCS) permits only single hepatic artery (HA) cannulation, limiting its use in grafts with variant arterial anatomy. Arterial reconstruction before NMP may overcome this limitation and expand the pool of grafts eligible for perfusion. We conducted a retrospective single-center cohort study of adult liver transplants utilizing OCS from January 2022 to September 2024. Allografts with variant hepatic artery anatomy requiring arterial reconstruction before NMP initiation were identified. Postoperative outcomes, including vascular and biliary complications, were compared between reconstructed and non-reconstructed grafts. Among 541 OCS-preserved grafts, 74 (13.7%) underwent arterial reconstruction. Compared with non-reconstructed grafts, reconstructed grafts had longer cross-clamp to cannulation time (2.8 vs. 2.4 h, p<0.001), but similar rates of early allograft dysfunction (23.0% vs. 20.8%, p=0.65), ischemic cholangiopathy (4.1% vs. 4.1%, p=1.00), and primary nonfunction (0.0% vs. 0.4%, p=1.00). Early (2.7% vs. 0.2%, p=0.05) and late hepatic artery thrombosis (HAT) (4.1% vs. 2.1%, p=0.40) were infrequent and not significantly different between non-reconstructed and reconstructed groups, respectively. Hepatic artery stenosis occurred more often in reconstructed grafts (12.2% vs. 4.1%, p=0.008), though most cases were managed with interventional radiology or surgical revision. Only one reconstructed graft required retransplantation due to vascular complications. Arterial reconstruction before NMP is safe and feasible, enabling successful perfusion and transplantation of liver allografts with variant HA anatomy. These findings support the broader application of NMP in anatomically complex donor livers.

The primary risk associated with liver transplant using macrosteatotic grafts is severe postreperfusion syndrome (PRS) and heightened sensitivity to ischemia-reperfusion injury. Utilization of normothermic machine perfusion (NMP) instead of static cold storage (SCS) may ameliorate PRS and other complications related to steatotic donor livers. All liver transplants from donor livers undergoing NMP with biopsy-confirmed moderate macrosteatosis (30%-60%) (N = 63) and mild macrosteatosis (10%-29%) (N = 135) at Mayo Clinic Florida and Mayo Clinic Arizona from January 2022 to February 2025 were included. These were compared with previously published cohorts receiving livers with SCS. Median NMP pump time was 13.8 hours. Patients in the moderate macrosteatosis NMP group had a lower rate of cardiac arrest with reperfusion (0% vs 8.3%; P = .02), PRS (9.5% vs 37.5%; P < .001), early allograft dysfunction (42.9% vs 76.4%; P < .001), and transfusion requirements (P < .001) than the moderate macrosteatosis SCS group. This was associated with improved patient and graft survival with NMP compared to SCS in both moderate and mild groups. NMP ameliorates perioperative issues of macrosteatotic donor livers, including significant reductions in PRS and early allograft dysfunction. NMP is also associated with superior patient and graft survival compared to SCS. Prolonged NMP pump time is recommended for steatotic livers to ensure adequate viability assessment and recovery from ischemic injury.

Background. Ex vivo machine perfusion (MP) has transformed organ preservation, offering significant benefits in liver transplantation (LT), particularly with high-risk donor grafts. However, adoption in the United States has been limited. We aimed to examine early adoption trends, surgeon perceptions, and barriers to implementing MP in the United States after Food and Drug Administration approval of MP platforms. Methods. A 23-question electronic survey was distributed to members of the American Society of Transplant Surgeons between October and November 2022, capturing attitudes and practices related to MP adoption. Responses from 96 surgeons representing 77 LT centers across 11 Organ Procurement and Transplantation Network regions were analyzed. Results. Forty-four respondents (48%) reported having an MP program at their institution. Adoption of MP was significantly more common in high-volume centers and those performing ≥20 donation after circulatory death (DCD) transplants annually (P < 0.001). MP utilization received strong support, with 88% endorsing its use for DCD liver allografts and 82% for donation after brain death allografts. Respondents cited MP’s ability to reduce ischemic cholangiopathy, enable graft repair, and facilitate viability assessment as key benefits. Normothermic MP was preferred for high-risk donor profiles, including DCD grafts, older donors, and steatotic livers, and was associated with an increased willingness to accept medically complex grafts compared with static cold storage. Barriers to MP utilization included program costs, personnel demands, and logistical complexities. Centers with higher proportions of privately insured patients were more likely to adopt MP. Despite these challenges, 84% of respondents expressed interest in future MP adoption. Conclusions. MP enhances graft utilization and outcomes, particularly for complex and high-risk donor livers, but widespread US adoption requires addressing financial and logistical barriers. Future efforts should focus on refining cost-effectiveness analyses, collaboration with organ procurement organizations and device companies, and developing standardized training to optimize MP integration and maximize its clinical impact on LT.

Combined heart-liver transplantation presents significant challenges, particularly in cases requiring extended ischemic times for managing hemodynamic instability post cardiac implantation. Advances in perfusion techniques, such as the normothermic machine perfusion pump, offer advantages over traditional static cold storage by maintaining organ viability during prolonged periods. We report the first successful combined heart-liver transplant using normothermic machine perfusion for both organs from a donation after circulatory death donor. The recipient is a 45-year-old male with ischemic cardiomyopathy-induced heart failure and end-stage liver disease secondary to congestive hepatopathy. Both organs, procured from a donation after circulatory death donor were preserved on the TransMedics Organ Care System and subsequently transplanted with total post crossclamp times of 7.75 hours for the heart and 15.25 hours for the liver. At 8 months post-transplant, the patient demonstrates stable cardiac and hepatic graft function. This case highlights the critical role of normothermic machine perfusion in optimizing organ quality and mitigating ischemic injury in multi-organ transplants involving donation after circulatory death donors. Our findings support the expanded use of normothermic machine perfusion to enhance organ utilization, particularly in complex, high-risk multi-organ transplants cases.

INTRODUCTION:Donation after circulatory death (DCD) allografts are underutilized in liver transplantation (LT) due to increased risk of complications. These risks stem from ischemic injury sustained during the total donor warm ischemia time (tDWIT), historically limited to 30 min. Normothermic machine perfusion (NMP) can mitigate these risks and facilitate LT of DCD grafts with extended tDWIT. We aimed to compare outcomes of DCD allografts with extended tDWIT preserved on NMP versus static cold storage (SCS). METHODS:This single-center study included adult DCD LT with tDWIT ≥ 30 from 2019 to 2023. Outcomes of NMP and SCS were compared including EAD, IC, graft survival, and patient survival. RESULTS:Among 68 DCD LT with tDWIT ≥ 30, 64.7% (n = 44) were preserved with NMP and 35.3% (n = 24) with SCS. No differences in donor or recipient demographics were observed. The median tDWIT was 33 min for NMP and 30.5 min for SCS (p < 0.01). Despite longer tDWIT, the NMP group had lower rates of EAD (4.5% vs. 66.7%, p < 0.01) and IC (2.3% vs. 29.2%, p < 0.01). One-year graft survival was higher in NMP (p < 0.01), and 1-year patient survival was comparable between groups (p = 0.18). CONCLUSION:NMP challenges traditional tDWIT constraints and can increase the pool of viable DCD allografts for transplantation.