Normothermic Regional Perfusion in Pancreas and Islet Transplantation from Donation After Circulatory Death: A Systematic Review

Abstract Objective: To compare pancreas transplantation, pancreas utilization and islet isolation and transplantation outcomes after normothermic regional perfusion (NRP) in donors after circulatory death (DCD) with those after super-rapid recovery (SRR) DCD and donation after brain death (DBD). Background: DCD pancreases are underused because of concern about warm ischemic injury. NRP restores oxygenated circulation before procurement and benefits the liver and kidney, but its effect on the pancreas and islets is uncertain. Methods: MEDLINE, Embase, Web of Science, Cochrane CENTRAL, ClinicalTrials.gov and congress proceedings were searched to October 2026 for comparative studies published from 2016. Risk of bias was assessed with ROBINS-I and certainty with GRADE; synthesis was narrative (SWiM). Results: Twelve reports from 4 independent data sources were included (10 on pancreas transplantation or utilization, 2 on islet isolation). In the UK registry (47 NRP vs 379 non-NRP DCD simultaneous pancreas-kidney transplants), 1-year pancreas graft survival was 93.6% vs 89.2% (adjusted HR for graft loss 0.56; 95% CI 0.17–1.80); in US registry data it was 91% after NRP, comparable to SRR. NRP was associated with numerically higher pancreas utilization (adjusted OR 1.6; 95% CI 0.98–2.64) and lower kidney delayed graft function (6% vs 33%). Compared with DBD, pancreas graft survival and donation rates after NRP were similar. In one program, islet yield was higher after abdominal NRP than after DCD procurement without NRP or DBD procurement (median 471,739 vs 218,750 and 206,522 islet equivalents). Certainty was very low for every outcome. Conclusions: Pancreas graft outcomes after NRP DCD procurement are comparable to those after both SRR DCD and DBD procurement, and NRP may increase utilization and islet yield to levels at or above DBD. NRP procurement alone should not be a reason to decline a DCD pancreas for transplantation or islet isolation; pooled registry analyses with standardized pancreas and islet outcomes are needed.