Comment on “salvage of Declined Extended Criteria DCD Livers Using In-Situ Normothermic Regional Perfusion”

We have read the excellent article written by Schurink et al1 with great interest and much appreciation. The authors show that abdominal normothermic regional perfusion is powerful in protecting extended criteria controlled donation after circulatory death (DCD) liver grafts that could be eventually transplanted with results comparable to donation after brain death liver graft transplantation. The conclusions drawn from this study are of great importance for improving the utilization rate of DCD livers. However, there are still some considerations needing further clarification. First, because each country has different standards for the use of DCD donor livers, whether the authors collect the specific reasons for the declined extended criteria DCD livers and the liver biochemical indicators at the time of decline, and if this part is included in the study, we can also see the liver protective potential of NRP more specifically. This will serve as a reference for other countries and may save a part of the liver that should be declined. Second, because of the powerful effect of abdominal normothermic regional perfusion, it can be seen that a large amount of the donor’s liver is wasted; it is time to unify the standard to reduce the declined rate of extended criteria DCD livers. It is possible to appropriately expand the criteria for liver selection during perfusion; however, this procedure must be performed with great caution to prevent severe postoperative complications. Furthermore, increasing evidence has shown that Hypothermic Oxygenated Machine Perfusion (HOPE) plays an excellent role in protecting the donor liver.2 We also suggest that the authors should actively include HOPE in the study to observe whether HOPE can protect the DCD liver and whether NRP + HOPE has a more positive effect, which will significantly improve the utilization rate of the DCD liver and minimize postoperative complications.