AUTHOR=Knight Simon Robert , Thomas Helen L. , Brown Rosemary , Brown Charlie , Brusby Kerrie , Arbon Emily , Silsby Laura , Newton Alice , Mehew Jennifer , Iqbal Aleema , Keen Katie , Bahar Syeda , Watson Christopher , Davidson Brian , Nasralla David , Ceresa Carlo , Fiore Barbara , Sherif Ahmed E. , Wilson Colin , Mahendran Balaji , Pollok Joerg-Matthias , Mateos Rebeca S. , Jassem Wayel , Gaurav Rohit , Oniscu Gabriel C. , Marshall Craig , Hann Angus , Ravikumar Reena , Coussios Constantin , Friend Peter J. 
  
TITLE=The perfused liver utilisation study (PLUS): challenges and innovation in the evaluation of an emerging technology
  
JOURNAL=Transplant International
  
VOLUME=Volume 39 - 2026
  
YEAR=2026
  
URL=https://www.frontierspartnerships.org/journals/transplant-international/articles/10.3389/ti.2026.16653
  
DOI=10.3389/ti.2026.16653
  
ISSN=1432-2277
  
ABSTRACT=Previous studies suggest that donor liver normothermic machine perfusion (NMP) reduces injury and enables functional assessment, resulting in an increase in utilisation. The PLUS study was designed to assess the impact of NMP availability on utilisation of livers at high risk of non-use. Using a threshold-crossing design, functional utilisation was assessed in a real-world retrospective registry-based control cohort. A predetermined efficacy threshold was set, and a prospective cohort was recruited in all UK liver transplant centres with NMP made available for all livers at high risk of non-utilisation. Availability of NMP resulted in a significant increase in functional utilisation (OR: 1.26, 95% CI: 1.04–1.53), but this did not exceed the pre-determined efficacy threshold. The threshold was exceeded in the subgroup of donation after circulatory death (DCD) livers, although this increase was reduced with adjustment for the use of normothermic regional perfusion. NMP was used in only 31% of retrieved livers, with variation between centres. The benefit of having NMP available was less than anticipated, likely due to low use in some centres associated with staff availability. Provision of NMP as a service, or centralisation of NMP use in assessment and recovery centres, may improve uptake.