Abstract
Donation after circulatory death (DCD) is a rapidly growing source of transplantable organs, but warm ischemia between circulatory arrest and cold preservation limits organ quality and utilization. Normothermic regional perfusion (NRP) restores oxygenated circulation to the abdominal (A-NRP) or thoracoabdominal (TA-NRP) organs in situ after death has been declared, with the aim of reversing ischemic injury before cold preservation and permitting functional assessment before organs are accepted. This narrative review traces NRP from the Maastricht classification and the Barcelona recirculation experiments to contemporary national programs. It summarizes the pathophysiology of warm ischemia–reperfusion injury and how NRP interrupts it, describes viability assessment, and synthesizes organ-specific outcomes for kidney, liver, heart, lung, and pancreas, including recent work from our program on delayed graft function (DGF) after NRP. European and United States frameworks are contrasted, and the ethical debate over TA-NRP and cerebral exclusion is examined. Observational studies, including meta-analyses, associate NRP with higher organ utilization, markedly less ischemic cholangiopathy in liver transplantation, and heart-transplant outcomes comparable to donation after brain death; evidence for DGF in kidney transplantation is supportive but less uniform. No randomized trials exist, technique remains heterogeneous, and ethical consensus on TA-NRP is incomplete, which together define the research agenda for the coming decade.