Normothermic Regional Perfusion, Ex Situ Normothermic Machine Perfusion, or Both? National Trends in Donation After Circulatory Death Liver Transplantation.

BACKGROUND: Rapid adoption of normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) has reshaped donation-after-circulatory-death (DCD) liver transplantation, but national patterns of single- versus dual-modality use and associated outcomes remain unclear. METHODS: Using the Scientific Registry of Transplant Recipients, we identified adult primary solitary DCD liver transplants in the United States from January 1, 2021 to March 31, 2025. Cases were categorized as: neither NRP/NMP, NMP alone, NRP alone, or combined NRP/NMP. We describe short term outcomes, temporal trends, center-level "perfusion phenotypes," donor and recipient characteristics, and organ sharing patterns. RESULTS: Among 6182 recipients, 2401 (38.8%) received neither NRP/NMP, 2348 (38.0%) NMP alone, 1008 (16.3%) NRP alone, and 425 (6.9%) both NRP/NMP. By 2024-2025, >80% of DCD grafts were perfused, with NMP alone the predominant strategy and NRP (alone or combined) increasingly adopted, especially for locally allocated grafts. Perfusion was used more often for grafts from older and obese donors and in high-volume programs, whereas lower-volume centers and younger donors more commonly underwent transplantation without NRP/NMP. All perfusion strategies were associated with superior early death-censored graft survival compared with no perfusion, without a clear short-term advantage of combined NRP/NMP over NRP or NMP alone. Overall patient survival was similar across strategies. CONCLUSION: NRP, NMP, and combined strategies now dominate DCD liver transplantation in the U.S., with preferential use in higher-risk donors and high-volume centers. Defining clinical scenarios where sequential NRP+NMP provides incremental benefit over single-modality perfusion remains a key priority.