En Bloc Kidney HOPE in DCD.

Hypothermic oxygenated machine perfusion (HOPE) is increasingly applied in donation after circulatory death (DCD) kidney transplantation to improve graft preservation, enable functional assessment, and reduce organ discard. In DCD settings characterized by prolonged mandatory agonal and warm ischemia phases, graft susceptibility to ischemia-reperfusion injury is amplified, rendering the preservation strategy particularly consequential. We describe a pragmatic technical workaround consisting of prolonged hypothermic perfusion of en bloc kidneys via aortic cannulation using a multiorgan perfusion system (VitaSmart Hypothermic Oxygenated Perfusion System, Bridge to Life Ltd., Northbrook, IL) operated under its standard renal perfusion settings. This approach allows continuous low-pressure perfusion, real-time monitoring, and the possibility of pharmacological intervention when renal-dedicated disposables are unavailable or when prolonged hypothermic preservation is required for logistical reasons. The technique was applied as a feasibility stress test in two DCD kidney grafts, which were perfused for 18 hours at controlled low pressure following an initial oxygenated flushing phase and maintained on continuous perfusion until implantation. The procedure proved technically stable and biologically informative, supporting its use as a rescue preservation strategy in selected DCD scenarios that require extended hypothermic oxygenated preservation and real-time graft assessment.