Hypothermic Oxygenated Perfusion Versus Static Cold Storage in Liver Transplantation: A Meta- Analysis of Randomized Trials.

BACKGROUND

Hypothermic oxygenated machine perfusion (HOPE) is an alternative to static cold storage (SCS) for liver graft preservation, aiming to reduce ischemia-reperfusion injury (IRI) and improve post-transplant outcomes.

METHODS

We systematically reviewed randomized controlled trials (RCTs) comparing HOPE with SCS in adult liver transplantation (MEDLINE, EMBASE, CENTRAL to July 2026). Outcomes included early allograft dysfunction (EAD), primary non-function (PNF), major postoperative complications, biliary complications, including non-anastomotic strictures (NAS), graft survival, and retransplantation.

RESULTS

Eight RCTs (984 patients; HOPE 461; SCS 523) met inclusion criteria. HOPE significantly reduced EAD (17.8% vs. 33.5%; RR 0.54, 95% CI 0.43-0.68; p < 0.00001) and PNF (0.4% vs. 3.6%; RR 0.26, 95% CI 0.09-0.75; p = 0.01). HOPE was associated with fewer major complications (Clavien-Dindo ≥ III) (41.2% vs. 50.7%; RR 0.80, 95% CI 0.70-0.93; p = 0.003), lower overall biliary complications (18.9% vs. 27.7%; RR 0.72, 95% CI 0.58-0.90; p = 0.004) and reduced NAS (3.3% vs. 7.6%; RR 0.43, 95% CI 0.23-0.82; p = 0.01). One-year graft survival was comparable, while retransplantation was reduced after HOPE (RR 0.35, 95% CI 0.14-0.84, p = 0.02).

CONCLUSION

HOPE improves early graft outcomes and reduces biliary morbidity and retransplantation compared with SCS, supporting its use to mitigate IRI.