Normothermic regional perfusion (NRP) has emerged as one of the most consequential innovations in modern liver transplantation, particularly in the context of controlled donation after circulatory death (cDCD). Historically, cDCD liver grafts have been associated with inferior outcomes compared with donation after brain death (DBD), largely due to warm ischemia and subsequent ischemia-reperfusion injury. These insults translated clinically into higher rates of early allograft dysfunction (EAD), primary nonfunction (PNF), ischemic cholangiopathy, and non-anastomotic biliary strictures (NAS). The review by Imai and colleagues provides a comprehensive and timely synthesis of how NRP is altering this paradigm by addressing the biological consequences of warm ischemia at their source. 

NRP involves restoring in situ, oxygenated, normothermic blood flow to donor organs after declaration of death, using extracorporeal circulation while maintaining safeguards against cerebral or coronary reperfusion. Two principal strategies are described: abdominal NRP (A-NRP), which perfuses abdominal organs only, and thoracoabdominal NRP (TA-NRP), which re-establishes cardiac activity and perfuses both thoracic and abdominal organs. Although initially developed in the early 2000s, NRP gained widespread adoption across Europe during the past decade and has more recently expanded in the United States following endorsement by professional societies.