Hypothermic oxygenated machine perfusion is associated with a lower risk of nonanastomotic biliary strictures after transplantation of livers obtained from donors after circulatory death, compared with conventional static cold storage, according to a study in the New England Journal of Medicine.

The Dual Hypothermic Oxygenated Perfusion of Donation After Circulatory Death (DHOPE-DCD) Liver Grafts in Preventing Nonanastomotic Biliary Strictures After Transplantation trial randomly assigned patients who were undergoing transplantation of a liver obtained from a donor after circulatory death to receive that liver either after hypothermic oxygenated machine perfusion (machine perfusion group) or after conventional static cold storage alone (control group). The incidence of nonanastomotic biliary strictures within 6 months after transplantation was the primary end point, and secondary end points included other graft-related and general complications.

A total of 160 patients underwent randomization: 78 received a machine-perfused liver and 78 received a liver after static cold storage only (4 patients did not receive a transplantation). The median age of the machine perfusion group was 60 years (interquartile range [IQR], 52-65), and 71% were male. The median age of control group members was 60 (IQR, 52-65), and 67% were male.

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Symptomatic nonanastomotic biliary strictures occurred in 5 of 78 patients (6%) in the machine perfusion group and in 14 of 78 (18%) in the control group (risk ratio, 0.36; 95% CI, 0.14 to 0.94; P =.03). After adjusting for stratification factors and prespecified donor risk factors in the log-binomial regression model, the investigators found similar results. These findings were then confirmed in the time-to-event analyses that used the Kaplan–Meier method and Cox regression analysis (hazard ratio, 0.32; 95% CI, 0.11 to 0.89; P =.03; P =.03 by the log-rank test).

Intraoperatively, postreperfusion syndrome, defined as a decrease of more than 30% in mean arterial blood pressure, was reported less frequently in the machine perfusion group than in the control group (12% vs 27%, respectively; adjusted risk ratio, 0.43; 95% CI, 0.20 to 0.91).

Early allograft dysfunction occurred in 20 machine-perfused livers (26%) and in 31 control livers (40%) (adjusted risk ratio, 0.61; 95% CI, 0.39 to 0.96). No cases of primary nonfunction were observed in the machine perfusion group, and 1 case occurred in the control group.

The cumulative number of treatments for nonanastomotic biliary strictures and related complications within 6 months after transplantation was lower by a factor of nearly 4 in the machine perfusion group compared with the control group, and the incidence of adverse events was similar between the 2 groups.

Disclosures: One of the study authors reported an affiliation with a pharmaceutical company. Please see the original reference for a full list of disclosures.


Van Rijn R, Schurink IJ, De Vries Y, et al. Hypothermic machine perfusion in liver transplantation—a randomized trial. N Engl J Med. Published online February 24, 2021. doi: 10.1056/NEJMoa2031532