Highlight
– Utilization of donation after circulatory death (DCD) donors for simultaneous liver-kidney transplantation (SLKT) in the US has markedly increased since 2018.
– Adoption of machine perfusion (MP) and normothermic regional perfusion (NRP) technologies has coincided with increased DCD-SLKT utilization.
– Graft and patient survival after DCD-SLKT are comparable to donation after brain death (DBD) SLKT despite higher preoperative risk profiles in DBD recipients.
– These findings support broader implementation of DCD donors for SLKT in appropriately selected candidates.
Study Background
Simultaneous liver-kidney transplantation (SLKT) is a vital therapeutic option for patients with concurrent end-stage liver and kidney disease. Traditionally, organs from donors after brain death (DBD) have predominated in SLKT, but increasing organ shortages have driven interest in expanding the donor pool by utilizing organs from donation after circulatory death (DCD) donors.
DCD transplantation carries inherent risks, including higher rates of ischemia-reperfusion injury, early allograft dysfunction, and vascular complications. Recent advances such as machine perfusion (MP) and normothermic regional perfusion (NRP) have been shown to mitigate these risks by improving organ preservation and reducing ischemia-related damage. However, national-level data examining clinical outcomes of DCD-SLKT in the era of these technologies remain sparse. This study addresses the gap by providing a comprehensive analysis of US transplant trends and outcomes in the modern era.
Study Design
This retrospective analysis utilized the United Network for Organ Sharing (UNOS) Standard Transplant and Research (STAR) registry to evaluate 10,687 adult primary SLKT cases performed between 2000 and 2025 across the United States. The study specifically compared clinical outcomes between DCD and DBD SLKT performed from 2020 to 2025, the period reflecting increased adoption of MP and NRP technology.
Patient and donor characteristics were balanced using propensity score matching (PSM) to minimize confounding. Kaplan-Meier analyses assessed liver graft and patient survival outcomes. Data on the utilization of organ preservation techniques such as liver MP, kidney MP, and NRP were integrated to evaluate temporal adoption trends.
Key Findings
Increasing Utilization of DCD Donors
The use of DCD donors for SLKT surged post-2018, reaching 29.3% of all SLKT cases by 2024. In that year, advanced preservation technologies were utilized in a majority of DCD-SLKT cases: liver MP in 58.1%, kidney MP in 82.9%, and NRP in 40.1%. These data indicate a practice shift favoring application of MP and NRP to enhance DCD allograft viability.
Recipient Baseline Differences
Prior to matching, recipients undergoing DBD-SLKT exhibited higher preoperative morbidity: 69.1% required dialysis versus 54.2% in DCD-SLKT, 51.0% were hospitalized preoperatively compared to 17.2% in DCD-SLKT, and median Model for End-Stage Liver Disease (MELD) score was significantly higher (30 vs. 23). These differences reflect sicker patients or more urgent transplantation indications in the DBD cohort.
Comparable Posttransplant Outcomes
Median follow-up was shorter in DCD-SLKT (706 vs. 364 days), consistent with increased recent DCD adoption. Despite this, liver graft and patient survival rates showed no significant differences between DCD and DBD groups, both before and after propensity score matching. This underscores that when appropriately selected and preserved, DCD organs can provide outcomes comparable to traditional DBD donors.
Impact of Machine Perfusion and NRP
The expanded use of MP and NRP technologies likely contributed to the comparable outcomes observed. These modalities improve oxygenation, reduce reperfusion injury, and potentially extend organ preservation time, addressing historically higher complication risks associated with DCD transplants.
Expert Commentary
The findings from Kusakabe et al. represent an important evolution in transplant medicine. By harnessing advanced perfusion platforms, centers are overcoming traditional barriers limiting DCD donor use in complex SLKT cases. This study confirms the clinical feasibility and safety of incorporating DCD allografts in SLKT with modern techniques, thereby expanding the donor pool amid persistent organ shortages.
However, the higher baseline illness severity in the DBD-SLKT cohort may reflect selection biases, as sicker patients may be preferentially allocated DBD organs. The shorter follow-up for DCD recipients calls for ongoing longitudinal studies to confirm durable outcomes. Additionally, specialized expertise and infrastructure required for NRP and MP may limit immediate widespread generalizability.
Guidelines may consider endorsing broader application of DCD donors for SLKT, contingent on recipient selection and availability of machine perfusion technologies. Further research into optimizing perfusion protocols and elucidating long-term outcomes will be critical to consolidate these promising findings.
Conclusion
This comprehensive US nationwide study of over 10,000 SLKT cases reveals an encouraging trend toward increased utilization of DCD donors paralleled by adoption of machine perfusion and normothermic regional perfusion technologies. Despite differing recipient risk profiles, graft and patient survival after DCD-SLKT are comparable to outcomes seen with established DBD transplantation. These results support the expansion of DCD-SLKT in clinical practice, provided rigorous recipient assessment and advanced organ preservation approaches are employed.
Future directions include longer-term outcome assessments, cost-effectiveness analyses of perfusion technologies, and refinement of protocols to maximize the potential of DCD organs in SLKT and other multiorgan transplant paradigms.
Funding and ClinicalTrials.gov
The original study did not specify external funding sources or clinical trial registration numbers.
References
1. Kusakabe J, Fernandes E, Bhamidimarri KR, et al. Revisiting Simultaneous Liver and Kidney Transplantation from Donors After Circulatory Death in the Era of Machine Perfusion Technologies: A US Nationwide Analysis of 10,687 Cases. Ann Surg. 2026 Jul 3. PMID: 42393772.
2. Nasralla D, Coussios CC, Mergental H, et al. A randomized trial of normothermic preservation in liver transplantation. Nature. 2018;557(7703):50-56.
3. Watson CJ, Jochmans I, Neuhaus P. Strategies to optimize the use of marginal donors for liver transplantation. Transpl Int. 2017;30(12):1163-1173.
4. Kumar V, Fernandez E, Saith S, et al. Machine perfusion in kidney transplantation: Clinical outcomes and future perspectives. Clin Transplant. 2024;38(2):e14724.