Real‐world implementation of normothermic machine perfusion: A detailed analysis of intraoperative and early postoperative impact

Abstract

BackgroundOutcome data for the great majority of liver normothermic machine perfusion (NMP) cases derive from the strict confines of clinical trials. Detailed specifics regarding the intraoperative and early postoperative impact of NMP on reperfusion injury and its sequelae during real‐world use of this emerging technology remain largely unavailable.MethodsWe analyzed transplants performed in a 3‐month pilot period during which surgeons invoked commercial NMP at their discretion. Living donor, multi‐organ, and hypothermic machine perfusion transplants were excluded.ResultsIntraoperatively, NMP (n = 24) compared to static cold storage (n = 25) recipients required less peri‐reperfusion bolus epinephrine (0 vs. 60 μg; p < .001) and post‐reperfusion fresh frozen plasma (2.5 vs. 7.0 units; p = .0069), platelets (.0 vs. 2.0 units; p = .042), and hemostatic agents (0% vs. 24%; p = .010). Time from incision to venous reperfusion did not differ (3.6 vs. 3.1; p = .095) but time from venous reperfusion to surgery end was shorter for NMP recipients (2.3 vs. 2.8 h; p = .0045). Postoperatively, NMP recipients required fewer red blood cell (1.0 vs. 4.0 units; p = .0083) and fresh frozen plasma (4.0 vs. 7.0 units; p = .046) transfusions, had shorter intensive care unit stays (33.5 vs. 58.4 h; p = .012), and experienced less early allograft dysfunction according to both the Model for Early Allograft Function Score (3.4 vs. 5.0; p = .0047) and peak AST within 10 days of transplant (619 vs. 1,181 U/L; p = .036). Liver acceptance for the corresponding recipient was conditional on NMP use for 63% (15/24) of cases.ConclusionReal‐world NMP use was associated with significantly lower intensity of reperfusion injury and intraoperative and postoperative care that may translate into patient benefit.

Normothermic Machine Perfusion Reduces Transfusion Requirements Even After Static Cold Storage: A 1 y Retrospective Single-center Analysis

“…Additionally, the need for transfusion of fibrinogen concentrate was reduced compared with patients who received a liver graft after SCS alone. Although studies have already described reduced transfusion requirements during liver transplantation after NMP, the surgical logistics of NMP differs significantly in the present study; Dixon et al 12 implemented NMP as fast as possible at the site of explantation, resulting in a short SCS time in the NMP after SCS group (2.1 [1.9–2.6] h). In the second publication showing a reduced need for blood products after NMP, NMP was also started immediately after explantation, resulting in an even shorter SCS time (1.5 [1.2–2.0] h), which also differed significantly from the cold storage duration of the SCS group.…”

“…In the present work, each donor organ underwent standard SCS during transportation from the donor hospital to our center, as NMP was not established until the graft arrived at our transplantation center, resulting in a markedly longer SCS time (6.8 [5.9-7.8] h) compared with previously mentioned studies, which did not differ from the SCS group. 9,12 Although the safe applicability of this strategy has already been demonstrated in principle, it was unclear whether the reported advantages of saving blood products could be transferred to this technique. 13 Another point to be underlined that distinguishes this study from previous studies is the administration of FFP.…”

“…In previous studies, significantly more FFP was administered to patients in the SCS group than in the NMP group, which makes it very likely that dilution led to lower values of concentration-based parameters such as hemoglobin and platelet count, increasing the number of transfused RBCs and PCs. 12 Several factors could be responsible for the observed notable savings in RBCs, PCs, and fibrinogen concentrate. First, it is known that the duration of CIT is causally related to the incidence of postoperative complications.…”

“…In previous studies, significantly more FFP was administered to patients in the SCS group than in the NMP group, which makes it very likely that dilution led to lower values of concentration-based parameters such as hemoglobin and platelet count, increasing the number of transfused RBCs and PCs. 12 …”