Ex situ normothermic machine perfusion reduces postreperfusion syndrome and improves patient and graft survival following liver transplant using macrosteatotic liver grafts.

The primary risk associated with liver transplant using macrosteatotic grafts is severe postreperfusion syndrome (PRS) and heightened sensitivity to ischemia-reperfusion injury. Utilization of normothermic machine perfusion (NMP) instead of static cold storage (SCS) may ameliorate PRS and other complications related to steatotic donor livers. All liver transplants from donor livers undergoing NMP with biopsy-confirmed moderate macrosteatosis (30%-60%) (N = 63) and mild macrosteatosis (10%-29%) (N = 135) at Mayo Clinic Florida and Mayo Clinic Arizona from January 2022 to February 2025 were included. These were compared with previously published cohorts receiving livers with SCS. Median NMP pump time was 13.8 hours. Patients in the moderate macrosteatosis NMP group had a lower rate of cardiac arrest with reperfusion (0% vs 8.3%; P = .02), PRS (9.5% vs 37.5%; P < .001), early allograft dysfunction (42.9% vs 76.4%; P < .001), and transfusion requirements (P < .001) than the moderate macrosteatosis SCS group. This was associated with improved patient and graft survival with NMP compared to SCS in both moderate and mild groups. NMP ameliorates perioperative issues of macrosteatotic donor livers, including significant reductions in PRS and early allograft dysfunction. NMP is also associated with superior patient and graft survival compared to SCS. Prolonged NMP pump time is recommended for steatotic livers to ensure adequate viability assessment and recovery from ischemic injury.