Comparative efficacy of advanced preservation strategies for donation after circulatory death liver grafts: A systematic review and network meta-analysis.

Donation after circulatory death liver grafts are exposed to warm ischemic injury, which may be worsened by prolonged cold storage time and attenuated by advanced preservation strategies. We searched PubMed, Embase, and Cochrane until June 2025, identifying 19 comparative studies for Bayesian network meta-analysis. Static cold storage (SCS), hypothermic oxygenated perfusion (HOPE, including dual-vessel HOPE), normothermic machine perfusion (NMP), normothermic regional perfusion (NRP), and hybrid sequences were compared. NRP was associated with improved 1-year graft survival (hazard ratio, 0.67; 95% credible interval, 0.54-0.85) and 1-year patient survival (hazard ratio, 0.74; 95% credible interval, 0.55-0.94) compared with SCS. HOPE was associated with significantly lower primary nonfunction and non-anastomotic biliary stricture (NAS). NMP was associated with significantly lower early allograft dysfunction, NAS, and peak transaminases. In the subgroup analysis, device-to-donor NMP was associated with significantly lower early allograft dysfunction and NAS than SCS, and with significantly fewer NASs than back-to-base NMP. Hybrid strategies beginning with NRP were associated with favorable survival estimates, although data remain limited. Overall, advanced preservation was generally associated with improved outcomes compared with SCS, although benefits varied across modalities and endpoints. As NRP evidence is entirely observational, these findings represent comparative effectiveness estimates rather than causal treatment effects.