Ischemia-free liver transplantation as a novel approach to improve survival and clinical outcomes in the acute-on-chronic liver failure scenario.

Acute-on-chronic liver failure (ACLF) is a life-threatening condition with high mortality. Ischemia-free liver transplantation (IFLT), a novel clinical approach avoiding ischemia-reperfusion injury, may offer significant benefits for patients with ACLF. This study included 30 patients with ACLF undergoing IFLT and 97 patients with ACLF undergoing conventional liver transplantation. After propensity score matching, the IFLT group comprised 28 patients, whereas the conventional liver transplantation group had 51 patients. In the propensity score matching cohort, Kaplan-Meier analysis confirmed IFLT improved patient and graft survival rates for patients with ACLF (log rank P = .018 and .018, respectively). The IFLT group demonstrated better 6-month patient survival rates (100% vs 74.5%, P = .009) and lower postreperfusion syndrome, shorter operative time, reduced intraoperative blood loss, and less blood product use. Furthermore, patients with ACLF receiving IFLT experienced less early allograft dysfunction, reduced intensive care unit stays, earlier extubation, faster consciousness recovery, and shorter time to first flatus. Accelerated recovery of liver, circulatory, respiratory, and coagulation functions was observed in the IFLT group, along with fewer acute kidney injuries. Notably, patients with ACLF receiving extended criteria donor livers in the IFLT group achieved better survival rates and clinical outcomes. Consequently, IFLT enhanced the survival rates and promoted the recovery of remote organs in patients with ACLF and improved clinical prognoses for those receiving extended criteria donor livers.