Normothermic regional perfusion (NRP)

Normothermic regional perfusion (NRP) is an in-situ organ-recovery technique used in controlled donation after circulatory death (DCD) in which, after death has been declared by circulatory criteria, extracorporeal circulation of the ECMO type is re-established to restore warm, oxygenated blood flow to the donor's organs before they are recovered.[1][2] When circulation is restored only to the abdominal organs it is termed abdominal NRP (A-NRP); when it is extended to the heart and lungs it is termed thoraco-abdominal NRP (TA-NRP).[1][3] The technique allows organs to be reperfused, reconditioned, and functionally assessed in the body before procurement, and proponents report improvements in organ utilization and in transplant outcomes compared with rapid (non-perfused) recovery.[1][2][3]

NRP is also one of the most contested practices in deceased donation. Because circulation is deliberately restored after a death that was declared on the basis of the cessation of circulation, critics argue that the practice is in tension with the determination of death and with the dead-donor rule, while proponents and several professional bodies argue that the donor remains dead and that the practice is ethically defensible.[2][3][4] This article presents both positions, attributed to their proponents, and does not take a side.

What NRP is and why it is used

In controlled DCD, organs sustain a period of warm ischemia between circulatory arrest and the start of cold preservation, which can damage organs and reduce the number that are usable. NRP addresses this by restoring in-situ circulation after death is declared: a perfusion circuit re-oxygenates and reperfuses the organs at body temperature, allowing recovery teams to repair early ischemic injury and to observe organ function (for example, hepatic and renal parameters, or, in TA-NRP, the recovered heart) before deciding whether to proceed.[1][2] Reported benefits include higher organ utilization rates and, for some organs, outcomes comparable to or better than rapid recovery; A-NRP is used principally for abdominal organs (liver, kidneys, pancreas), and TA-NRP additionally enables DCD heart recovery.[1][2][3]

Technique

After declaration of death by circulatory criteria and completion of the no-touch observation period, the donor is cannulated for extracorporeal circulation and regional perfusion is started.[1][3] A defining feature is the deliberate exclusion of cerebral circulation: in TA-NRP, the great vessels of the aortic arch supplying the brain are clamped or ligated (and may be vented) so that the restored circulation does not reperfuse the brain; analogous measures exclude cerebral flow in abdominal NRP.[2][3] Perfusion is maintained for a defined interval while organs are assessed, after which organs are recovered and cold-preserved or transferred to ex-situ machine perfusion as in other organ procurement.[1][3]

The ethical debate

NRP is genuinely contested, and authoritative bodies disagree. The two principal positions are summarized below, each attributed to its proponents.

The objection

Critics argue that restoring systemic circulation after a death declared on the basis of the permanent cessation of circulation is in tension with the premise of that declaration. In an analysis published in the Hastings Center Report, Omelianchuk and colleagues argue that NRP "restores the donor's circulation and thus invalidates a death declaration based on permanent cessation of circulation," and conclude that the practice is "neither ethical nor prudent."[5] The American College of Physicians (ACP), in a 2021 statement, raised concerns about whether the cessation of function is genuinely irreversible when circulation is subsequently restored, characterized NRP in controlled DCD as more accurately described as organ retrieval after the induction of brain death, warned of risks to public trust and to vulnerable populations, and called for a pause in the practice pending resolution of the ethical and legal questions.[6] A specific concern in this line of argument is that the clamping or exclusion of cerebral circulation is performed in order to preserve the validity of the death determination, that is, to ensure the brain is not reperfused, which critics contend reveals a tension at the heart of the practice.[5][6]

The defense

Proponents and several professional bodies argue that the donor remains dead throughout NRP and that the practice satisfies the dead-donor rule. On this view, the determination of death rests on the permanence standard: a valid decision has been made to withdraw treatment and not to resuscitate, so circulation has permanently ceased and the patient is dead before perfusion begins.[2][3] Defenders hold that because cerebral perfusion is deliberately and reliably prevented, the brain is not recirculated and the donor cannot be restored to a living state, and that NRP is ethically analogous to other accepted DCD practices and to ex-situ machine perfusion.[2][3] The American Society of Transplant Surgeons (ASTS), in a 2024 consensus statement and accompanying standards, concluded that NRP, including TA-NRP, can be performed ethically when established safeguards (independent death declaration, exclusion of cerebral circulation, transparency, and consent) are followed, and issued technical and operational standards to that end.[3][7] Some authors further argue that, where feasible, NRP is not merely permissible but advantageous because it increases the number and quality of transplantable organs.[2][3]

Professional and regulatory positions

The OPTN Ethics Committee issued a white paper, Ethical Analysis of Normothermic Regional Perfusion, developed in 2023 and approved by the OPTN Board in 2024. The paper analyzes six themes, compatibility with the dead-donor rule, donor-harm risk, consent uncertainties, stakeholder trust, justice, and potential benefits, and explicitly reports that there is no consensus on the ethical permissibility of NRP; as a white paper it informs discussion but is not OPTN policy.[4] Society positions diverge: the ACP statement is cautionary and called for a pause,[6] while transplant-surgery and cardiothoracic bodies (including the ASTS and collaborating societies) have published consensus statements and technical standards supporting carefully governed NRP.[3][7] Practice also varies internationally: NRP is established in Spain and the United Kingdom and used in other European countries, while in the United States it expanded amid active ethical debate, with some institutions and regions pausing or declining the practice during the controversy.[2][3][6] As of 2026, NRP remains in use in the United States without a single uniform national policy, and OPTN policy work and ethical analysis on the practice are ongoing.[3][4]

Current status

As of 2026, NRP, both A-NRP and TA-NRP, is performed in a growing number of programs internationally and in the United States, where it has materially contributed to the rise in DCD heart and abdominal-organ recovery, while remaining subject to unresolved ethical disagreement and to continuing OPTN policy development.[3][4] These are point-in-time observations; readers should re-confirm the regulatory status against the linked primary sources.

See also

• Donation after circulatory death (DCD)
• The dead-donor rule
• Organ procurement (recovery surgery)
• Organ preservation and machine perfusion
• Donation after brain death (DBD)

References

• Hessheimer AJ, et al.; and DCD/NRP reviews. Normothermic regional perfusion in controlled DCD: abdominal (A-NRP) and thoraco-abdominal (TA-NRP) techniques. (Secondary review of NRP technique and reported utilization benefits.)
• O'Rourke L, et al. Donation after circulatory death: a narrative review of current controversies, attitudes, and the evolving role of regional perfusion technology. AME Medical Journal. https://amj.amegroups.org/article/view/9066/html
• Wall AE, Fiedler AG, et al. The American Society of Transplant Surgeons Consensus Statement on Normothermic Regional Perfusion. Transplantation / J Am Coll Surg, 2024. PMID:38254280. https://pubmed.ncbi.nlm.nih.gov/38254280/ (and associated ASTS NRP Standards: PMID:39012956, PMID:39012935.)
• OPTN Ethics Committee. Ethical Analysis of Normothermic Regional Perfusion (white paper; developed 2023, OPTN Board-approved 2024). Organ Procurement and Transplantation Network / HRSA. https://optn.transplant.hrsa.gov/news/white-paper-analyzes-ethical-issues-in-normothermic-regional-perfusion/, full text: https://optn.transplant.hrsa.gov/media/143lxeha/ethics_nrp_wp_dec23.pdf (states no consensus on ethical permissibility).
• Omelianchuk A, Capron AM, Ross LF, Derse AR, Bernat JL, Magnus D. Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion. Hastings Cent Rep. 2024;54(4):14-23. doi:10.1002/hast.1584. https://onlinelibrary.wiley.com/doi/10.1002/hast.1584
• American College of Physicians. Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): Statement of Concern. 2021. https://www.acponline.org/sites/default/files/documents/clinical_information/resources/end_of_life_care/ethics_determination_of_death_and_organ_transplantation_in_nrp_2021.pdf, newsroom: https://www.acponline.org/acp-newsroom/the-american-college-of-physicians-says-organ-procurement-method-raises-significant-ethical-concerns
• Schwartz GS, et al. Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion (ASTS/ISHLT/STS/AATS working group). Ann Thorac Surg. 2024. PMID:39012953. https://www.annalsthoracicsurgery.org/article/S0003-4975(24)00567-8/fulltext