Organ Assessment and Repair Centers: Navigating Practical Hurdles in a New Era of Transplantation

Solid organ transplantation remains limited by the availability and quality of donor organs. Despite advances in donor management and allocation policy, a substantial proportion of recovered organs are discarded, and increasing reliance on extended-criteria and donation after circulatory death donors introduces additional uncertainty regarding graft viability. Traditional preservation using static cold storage provides a limited opportunity to assess organ function or intervene therapeutically before transplantation. Recent advances in machine perfusion technologies have begun to reshape this paradigm by enabling donor organs to be maintained and evaluated ex vivo. Normothermic perfusion platforms allow real-time physiologic assessment and biochemical monitoring, while hypothermic approaches primarily support preservation with more limited capacity for functional evaluation. These capabilities have created the foundation for the development of organ assessment and repair centers (ARCs), specialized platforms designed to centralize perfusion-based organ evaluation and potential rehabilitation. This overview examines the rationale for regionalized ARC systems and their potential to expand donor organ utilization while improving graft preservation and viability assessment. We discuss the clinical and logistical advantages of centralized perfusion platforms, including mitigation of ischemia/reperfusion injury, improved viability assessment, centralized expertise, integrated research infrastructure, and opportunities for organ-directed therapeutic interventions. We also examine the practical challenges associated with ARC implementation, including financial costs, infrastructure requirements, regulatory oversight, and logistical coordination across transplant networks. As machine perfusion technologies continue to evolve, ARCs may provide the infrastructure needed to integrate advanced preservation, diagnostics, and therapeutic interventions into routine transplant practice, enabling more effective utilization of the donor organ pool.