Pushing the Limit for Marginal Grafts in the Era of Machine Perfusion: A Tale of HOPE From a Leading Italian Institution.

BACKGROUND

The advent of machine perfusion (MP) has significantly improved post-liver transplantation (post-LT) outcomes, potentially enabling the use of increasingly marginal grafts and expanding the organ donor pool.

METHODS

We present a retrospective cohort study of consecutive adult patients who underwent LT between 2018 and 2023 at a leading Italian institution. The objective was to evaluate outcomes following the use of hypothermic oxygenated perfusion (HOPE) in high-risk grafts.

RESULTS

A total of 507 patients were included in the final analysis, of whom 420 (83%) received extended criteria donor (ECD) grafts. Among ECD grafts, 62 (15%) were from donation after circulatory death (DCD) donors, and 64 (15%) were previously discarded by other centers. HOPE was applied in 248 (49%) cases. Recipients in the HOPE group experienced significantly lower rates of early allograft dysfunction (EAD) (20% vs. 32%, p = 0.007), primary nonfunction (2% vs. 7%, p = 0.017), and severe postoperative complications (Clavien-Dindo grade ≥ 3b) (19% vs. 28%, p = 0.026). Notably, marginal grafts treated with HOPE achieved survival outcomes comparable to those of standard risk.

CONCLUSIONS

HOPE is associated with improved outcomes in LT using ECD grafts and can enable the safe use of higher-risk organs with acceptable results when performed in experienced centers.