Beyond the learning curve: Advances and ongoing controversies in donation after circulatory-death liver transplantation

Donation after circulatory death (DCD) liver transplantation is a growing strategy to mitigate organ shortages but was initially hampered by poor outcomes and high complication rates. This narrative review critically examines recent advances, unresolved controversies, and provides a brief institutional perspective on DCD liver transplantation. We conducted a comprehensive review of recent literature on DCD liver transplantation, focusing on innovations in donor and recipient selection, procurement techniques, dynamic perfusion technologies, and complication management. Our institutional experience with dynamic perfusion is summarized in context. Advances such as refined donor and recipient selection, improved procurement protocols, and the adoption of dynamic perfusion techniques—including normothermic regional perfusion (NRP), normothermic machine perfusion (NMP), and hypothermic oxygenated perfusion (HOPE)—have significantly improved graft preservation and post-transplant outcomes. These developments have led to reduced rates of graft failure, primary nonfunction, and ischemic cholangiopathy, both in the recent literature and our center's recent practice. Contemporary DCD liver transplantation has achieved outcomes approaching those of DBD transplantation due to multidisciplinary innovations: better patient and graft selection, optimized surgical protocols, improved perioperative care, and the introduction of dynamic perfusion. However, important challenges remain regarding ethical considerations, cost-effectiveness, and worldwide standardization.