Hypothermic-Oxygenated Perfusion in Pediatric Liver Transplantation: Beyond Graft Preservation, Facilitating Safer Surgeries in a Donor-Limited Environment.

BACKGROUND

Pediatric liver transplantation (PLT) increasingly faces a landscape of limited and suboptimal donor grafts, alongside a rising proportion of complex recipients. Hypothermic-oxygenated perfusion (HOPE) mitigates ischaemia-reperfusion injury and may support graft function in this context.

OBJECTIVE

To evaluate feasibility and outcomes of backbench HOPE in complex PLT, compared with a historical cohort of static cold storage (SCS).

METHODS

Prospective cohort of 22 PLT recipients who received a HOPE-perfused liver graft between September 2024 and December 2025, compared with a historical cohort of 32 PLT recipients transplanted after SCS. Variables: donor/recipient/graft characteristics, surgical complexity markers, postoperative complications, and survival outcomes.

RESULTS

Recipients in both groups had a similar baseline profile, but the HOPE group showed a trend toward greater surgical complexity, with longer hepatectomy times (2.3 vs. 2.1 hours, p = 0.002). Cold ischaemia time was shorter (5.8 [5.1-6.7] vs. 8 [6.8-9.1] hours; p < 0.001). Median HOPE perfusion was 4.1 hours. Seventy-seven percent of the grafts were reduced/split on HOPE. Postoperative complications did not differ significantly between groups, and no biliary strictures occurred in the HOPE group compared with five in the SCS group. At 1 year, although patient survival was numerically lower in the HOPE group (77.3% vs. 90.6%, p = 0.200), all deaths occurred with functioning graft; and death-censored graft survival (95.5% vs. 96.8%, p = 0.880) was comparable.

CONCLUSION

In a donor-limited environment with complex recipients, routine backbench HOPE showed graft outcomes and survival comparable to a historical SCS group. These findings suggest a potential role for HOPE beyond graft preservation, supporting surgical synchronization in complex PLT.