The Hitchhiker's guide to isolated organ perfusion: a journey to 2040

Abstract

Building on the established success of hypothermic machine perfusion (HMP) and emerging normothermic platforms, machine perfusion is poised to guide a journey toward 2040, transforming organ transplantation into an era of integrated preservation, viability assessment, and ex situ therapy. While renal HMP today reduces delayed graft function and improves graft survival, the next two decades will centre on adaptive platform trials in normothermic perfusion, predictive AI-driven biomarkers, and unified registries to validate robust surrogate endpoints. Centralised Assessment and Reconditioning Centres (ARCs) will streamline 24/7 workflows, combining advanced imaging, molecular assays, and gene or cell therapies to repair and optimise grafts ex-vivo. Health economics will shift toward dynamic, value-based reimbursement, addressing equity and cost-effectiveness across diverse systems. Regulatory frameworks will adapt through CONSORT-style reporting and direct device-to-registry data integration, ensuring transparency and reproducibility. By 2040, these convergent advances in HMP, normothermic machine perfusion (NMP), along with translational research will not only enhance graft utilisation and patient outcomes but will redefine transplantation paradigms through precision graft management, optimised logistics, and new indications such as extracorporeal organ support.

Keywords: HMP; HOPE; NMP; Organ Perfusion; Preservation.

Figure 1

Concept as an ARC as capacitor, using data from Oxford transplant centre (2020–2022). The vertical bars describe the current random frequency of organ transplants. By acting as a “capacitor”, the combination of an ARC system and reliable prolonged perfusion could shift the pattern to the solid line, improving logistics and increasing the total number of transplants that are possible given a fixed maximum operating capacity. Demonstrating that a unit like Oxford doing more than 200 transplant per year would produce an average of 0.3–1 transplant per day. Meaning that without increasing unit infrastructure one could more reliably increase the annual transplant output to closer to 350, with at least 1 transplant per day.