AUTHOR=Ramírez‐Esteban José , Sarrió Ezequiel , Ruiz‐Pacheco Alberto , Cots Ana , Romero‐García Nekane , Badenes Rafael 
  
TITLE=Normothermic regional perfusion in controlled donation after circulatory death liver transplantation: an updated systematic review and meta-analysis versus non-NRP and brain-death donors
  
JOURNAL=Transplant International
  
VOLUME=Volume 39 - 2026
  
YEAR=2026
  
URL=https://www.frontierspartnerships.org/journals/transplant-international/articles/10.3389/ti.2026.17154
  
DOI=10.3389/ti.2026.17154
  
ISSN=1432-2277
  
ABSTRACT=Normothermic regional perfusion (NRP) may mitigate ischemic injury in controlled donation after circulatory death (cDCD) liver transplantation. We updated the most recent meta-analysis (search closed June 2023) by incorporating subsequent evidence and comparing NRP with non-NRP cDCD and with donation after brain death (DBD). We performed a systematic review of five databases and random-effects meta-analyses; dichotomous outcomes were pooled as risk ratios, the Mantel-Haenszel estimator was preferred for rare events, pooled incidences used a logit-binomial model, risk of bias was assessed with ROBINS-I and certainty with GRADE. Twenty observational studies were included (1776 NRP-cDCD liver recipients). Versus non-NRP cDCD, NRP reduced ischemic cholangiopathy (risk ratio 0.16, 95% confidence interval 0.09–0.28; number needed to treat 9), graft loss (0.41, 0.32–0.54), recipient death (0.46, 0.34–0.62), hepatic artery thrombosis (0.51, 0.30–0.85), other biliary complications (0.49, 0.32–0.73) and primary non-function (0.51, 0.28–0.94); these reductions persisted after excluding grafts managed with ex situ machine perfusion. Versus DBD, no outcome differed significantly. Pooled ischemic cholangiopathy incidence was 1.8%, 12.7% and 1.2% with NRP, non-NRP and DBD. NRP markedly reduces ischemic cholangiopathy and improves other outcomes versus non-NRP cDCD, approaching DBD; the evidence remains observational, with moderate-to-serious risk of bias.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420261404939, identifier PROSPERO CRD420261404939.