Normothermic regional perfusion (NRP) has potential to increase the number and quality of transplanted organs. Most reports showing advantages of NRP have been from transplant centers, but not all centers perform NRP. These advantages could be broadened if organ procurement organizations (OPOs) also performed NRP. We report donation and transplantation outcomes of our first 90 OPO-based NRP non-thoracic donors, divided into 3 eras (n=30 each). Comparisons were made with DCD-direct procurement (DP; n=270) and donation after brain death (DBD; n=729) donors. NRP donor median age was 53 years, compared to DP (48 years, p=0.004) and DBD (44 years, p<0.001) donors. NRP liver utilization (69%, 18 accepting centers) was superior to DP (17%, p<0.001) and not significantly different from DBD utilization (79%, p=0.27) on multivariate analysis. By era, NRP liver utilization progressively increased: 53%, 70%, 83% (p=0.04). NRP kidney use rate (71%) was higher than in DP (60%, p=0.02) and not significantly different from DBD (76%, p=0.15), especially among older donors. NRP kidney DGF incidence (29%) was lower than in DP (47%, p=0.001) and not significantly different from DBD (32%, p=0.53) donors. OPO-based NRP can provide more livers and kidneys to multiple transplant centers and improve outcomes from non-thoracic organ donors.

Introduction: Fibrolamellar carcinoma (FLC) is a rare liver cancer that predominantly affects younger patients without a history of liver disease. Surgical resection is the cornerstone of therapy and represents the best potentially curative treatment option. Modest objective responses with cytotoxic chemotherapy alone or combined with immune checkpoint inhibitors (ICIs) have been reported; however, there are no established systemic therapy regimens for unresectable or metastatic FLC. Case Presentation: We report a case of a 23-year-old woman with FLC who presented with a 11.5 × 8.3 cm left liver mass and subsequently underwent resection as initial therapy. Molecular analysis of her surgical tissue revealed a DNAJB1-PRKACA fusion gene. The patient developed biopsy-proven recurrent FLC with multiple liver lesions but without any distant metastatic disease only 3 months after initial resection. In light of emerging data, the patient was treated with a novel triple therapy regimen including 5-fluorouracil (5-FU), interferon (IFN) alfa-2b, and nivolumab. Partial radiographic response was achieved after 4 treatments and complete response was achieved after 12 cycles with the combination. The patient received 2 more doses of 5-FU/IFN alfa-2b without nivolumab and underwent orthotopic liver transplantation (OLT) 6 months after the last dose of ICI. Pathological examination of the explanted liver remarkably confirmed pathologic complete response. She remains recurrence-free and is on active surveillance. Discussion/Conclusion: For patients with unresectable/recurrent FLC with no distant disease, the combination of 5-FU, IFN alfa-2b, and nivolumab could be an effective systemic therapy option. The use of this chemoimmunotherapy regimen to downstage FLC prior to OLT may be worth investigating further.

Background and Objectives: Normothermic regional perfusion (NRP) is an effective technique to improve recipient outcomes. However, no valid methods for determining liver viability exist. Identifying relevant biological markers with clinical correlation to liver viability and recipient clinical outcomes is imperative to improve decision-making. Materials and Methods: Fifty-four donors undergoing NRP and their recipients were included. FMN was measured at the start, 1 h, and end of NRP. Lactate was measured at the start, 30, 60, and 90 min of NRP. Primary outcomes were early allograft function using the early allograft dysfunction (EAD) criteria and the model for early allograft function (MEAF). Secondary outcomes included the association with donor warm ischemia time (DWIT), stratified by 30 min. Spearman’s rho assessed correlations. Results: Forty (74%) livers were transplanted, with 5 (12.5%) recipients developing EAD and the mean MEAF score was 3.13 (1.49). FMN at all time points was significantly greater in the EAD group compared to the non-EAD group and was significantly correlated with the MEAF score (Peak FMN: rho = 0.507, p = 0.001). FMN during perfusion did not differ between DWIT < and ≥30 min. Lactate levels were similar across all groups and did not discriminate for adverse allograft outcomes. However, lactate levels during perfusion were higher in the DWIT ≥ 30 min group. Conclusions: These findings suggest that during NRP, elevated FMN, but not lactate, is associated with early allograft function.

Transplant centers hold the key to accelerating organ use and transplanting more patients more efficiently. However, not all transplant procedures are alike, as organ complexity and patient comorbidities can dramatically increase the risk of the procedures, demanding unique skills and more extensive resources to achieve good outcomes. What if transplant centers could emulate aspects of the trauma center model to ensure that necessary capabilities are consistently applied and uniformly available for all levels of organ risk and patient health? The proposed model recognizes that some transplant centers would have the capacity and aligned resources to care for the most complex patients and different types of organ transplants. Other transplant centers would leverage their available resources for less complex patients and organs. Importantly, this model also provides a template for regular stakeholder review of transplant program performance and episodic certification of transplant center resources. By moving to a tiered trauma center-like certification model, transplant centers, organ allocation policy, and patients could be triaged to the center most capable of providing them timely, effective care.

Normothermic regional perfusion (NRP) adoption for donation after circulatory death (DCD) liver transplantation in the US has been growing, but there remains a higher rate of non-utilization of NRP DCD liver grafts as compared to donation after brain death liver grafts. Six transplant centers and one organ procurement organization (OPO) with substantial NRP liver procurement experience performed retrospective reviews of all NRP procurement attempts from September 1, 2021 until March 1, 2024, identifying opportunities for utilization. Five of the 6 transplant centers had prospectively collected data on all accepted livers with NRP intent. The transplant center intention to utilize DCD donors included 329 livers accepted for transplantation prior to withdrawal, 252 (76.6%) potential donors expired within the hospital timeframe for donation, and 168 (66.7%) livers were transplanted. Fifty-seven opportunities for utilization were identified by transplant centers plus 11 from the OPO: most were due to exceeding a functional warm ischemic time limit (n=26), other reasons (n=17) and functional assessment (n=16). The lessons learned by centers in this study provide guidance for newer NRP centers and for OPOs in identifying opportunities for utilization of NRP DCD grafts that have historically been declined. Export

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