Impact of Normothermic Regional Perfusion on Clinical Outcomes in Kidney Transplantation from Donors After Circulatory Death: A US Nationwide Analysis of 38,048 Cases.

Abstract

We evaluated the impact of normothermic regional perfusion (NRP) on short- and mid-term outcomes of kidney transplantation (KT) using donation after circulatory death (DCD). We further examined the influence of NRP duration and identified subgroups most likely to benefit from its use. NRP has recently gained adoption in DCD-KT as a means to mitigate donor warm ischemic injury. However, its effect on graft and patient outcomes particularly beyond one year remains uncertain, and the role of NRP duration and subgroup-specific benefits has not been well defined. Using UNOS STAR files, we analyzed 21,010 primary adult DCD-KT cases performed between 2020-2025. Based on prior literature, cases were classified as non-NRP (0-30 min from circulatory death to cross-clamp) or NRP (30-180 min). Propensity score matching (PSM) adjusted for donor and recipient differences. Kaplan-Meier methods assessed graft and patient survival. After PSM, NRP was associated with reduced DGF (30.3% vs. 49.7%), shorter hospital stay (median 4 vs. 5 d), and improved overall graft and patient survival (P=0.007 and 0.047). No difference was observed in overall graft survival between short and long NRP durations (P=0.62). Subgroup analyses for one-year graft survival revealed that the benefit of NRP was more evident in cases of elderly recipients or donors, high donor BMI, higher KDPI, and prolonged pre-transplant dialysis. NRP improved both short- and mid-term outcomes, including three-year/overall graft/patient survival. NRP duration did not significantly affect overall graft survival. The benefits of NRP were pronounced in high-risk subgroups.