Successful Ex Situ Reduction During Hypothermic Oxygenated Machine Perfusion in a Severely Steatotic Graft From a Donor After Brain Death: An Anecdote?

Marginal liver grafts, such as those from cardiac death donors and donors with steatotic organs, are highly vulnerable to ischemia-reperfusion injury. In addition, ex situ graft alteration, either by reduction or splitting, will prolong the static cold storage time and amplify the ischemia-reperfusion injury. Hypothermic oxygenated machine perfusion has the potential to end the oxygen deprivation during preservation and accordingly improve outcomes in some marginal grafts that have been traditionally discarded. We present a case of a severely steatotic graftfrom a donor after brain death for which the graft was reduced ex situ during hypothermic oxygenated machine perfusion via the portal vein to shorten static cold storage duration. The liver was successfully transplanted into a 67-year-old adult recipient. Despite having a high donor risk index (10.8) and macrosteatosis of 50%, the graft showed early good function, and the recipient was discharged home with no complications and normal liver function tests in less than 2 weeks. Although this represents an anecdotal observation, we believe, in this case,thatthe possibility to provide oxygen during hypothermic organ storage enabled graft reduction without prolonging the cold ischemia time. The endischemic hypothermic oxygenated machine perfusion has the potential to transform the traditional established strategies for organ selection and preservation.