In many countries, donation after circulatory death (DCD) liver grafts are used to overcome organ shortages; however, DCD grafts have been associated with an increased risk of complications and even graft loss after liver transplantation. The increased risk of complications is thought to correlate with prolonged functional donor warm ischaemia time. Stringent donor selection criteria and utilisation of in situ and ex situ organ perfusion technologies have led to improved outcomes. Additionally, the increased use of novel organ perfusion strategies has led to the possibility of reconditioning marginal DCD liver grafts. Moreover, these technologies enable the assessment of liver function before implantation, thus providing valuable data that can guide more precise graft-recipient selection. In this review, we first describe the different definitions of functional warm donor ischaemia time and its role as a determinant of outcomes after DCD liver transplantation, with a focus on the thresholds proposed for graft acceptance. Next, organ perfusion strategies, namely normothermic regional perfusion, hypothermic oxygenated perfusion, and normothermic machine perfusion are discussed. For each technique, clinical studies reporting on the transplant outcome are described, together with a discussion on the possible protective mechanisms involved and the functional criteria adopted for graft selection. Finally, we review multimodal preservation protocols involving a combination of more than one perfusion technique and potential future directions in the field.

在许多国家，循环死亡后捐献（DCD）肝移植被用来克服器官短缺；然而，DCD 移植物与肝移植后并发症甚至移植物丢失的风险增加有关。并发症风险的增加被认为与功能性供体热缺血时间延长有关。严格的供体选择标准以及原位和异位的利用器官灌注技术改善了结果。此外，新型器官灌注策略的使用增加使得修复边缘 DCD 肝移植成为可能。此外，这些技术可以在植入前评估肝功能，从而提供有价值的数据来指导更精确的移植受体选择。在这篇综述中，我们首先描述功能性热供体缺血时间的不同定义及其作为 DCD 肝移植后结果决定因素的作用，重点关注移植物接受的阈值。其次，器官灌注策略，即常温局部灌注, hypothermic oxygenated perfusion, and normothermic machine perfusion are discussed. For each technique, clinical studies reporting on the transplant outcome are described, together with a discussion on the possible protective mechanisms involved and the functional criteria adopted for graft selection. Finally, we review multimodal preservation protocols involving a combination of more than one perfusion technique and potential future directions in the field.