Role of Machine Perfusion in Liver Transplantation.

Given the current severe shortage of available livers for transplantation, there is an urgent need to maximize the utilization of donor organs. One of the strategies to increase the number of available livers for transplantation is to improve organ utilization through the use of elderly, overweight, or organs donated after circulatory death (DCD). However, the utilization of these “marginal” organs was associated with an increased risk of early allograft dysfunction, primary non-function, ischemic biliary complications or even re-transplantation. Ischemia–reperfusion (IR) injury is a key mechanism in the pathogenesis of these complication. Although conventional static cold preservation provides some protection against IR injury, more-advanced preservation methods are needed to improve outcomes after transplantation of marginal livers or obtained after circulatory death. Among the most promising strategies is the utilization of ex-vivo machine perfusion. Recently, a variety of perfusion machines have received approval for clinical use, each differing in terms of perfusion temperature and oxygenation capabilities. Overall, clinical trials have demonstrated that these devices have resulted in superior posttransplant outcomes and increased utilization of marginal livers, leading to their widespread adoption. In this review, we aim to provide both the rationale and up-to-date clinical evidence for machine perfusion, along with its potential future applications.