Nationwide Hypothermic Machine Perfusion for ECD and DCD Kidney Transplantation in Belgium: One-Year Outcomes and Impact on Transplant Rates and Budget Impact Analysis

In September 2022, Belgium implemented a nationally reimbursed HMP service for all ECD and DCD kidneys procured and transplanted within the country. We retrospectively analyzed data from 242 kidney transplantations preserved with continuous HMP between October 2022 and September 2023. Active oxygenation (HMPO₂) was applied in DCD donors aged >50 years. One-year outcomes for all HMP kidneys included delayed graft function (DGF) in 14.4%, estimated glomerular filtration rate of 50 mL/min/1.73 m², 10.1% acute rejection, 96.3% death-censored graft survival, and 98.3% patient survival. DGF rates were lower in ECD kidneys (9.1%) and in DCD ≤50 years (9.5%), while higher in DCD >50 years (19.6%). National transplantation rates of DCD kidneys significantly increased from 90 to 175 per year (p < 0.0001), but not for ECD kidneys (from 45 to 54 per year (p = 0.2965) post-HMP implementation without affecting kidney export. The annual cost savings from reduced dialysis requirements were estimated at €3.59 million. The national implementation of a centralized HMP service in Belgium led to excellent one-year transplant outcomes, increased utilization of ECD and DCD kidneys, and substantial healthcare cost savings. These findings support HMP, and where appropriate HMPO₂, as the new standard of care for kidney preservation in Belgium, with potential implications for broader international collaboration.