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 ACLF patients. This study included 30 ACLF patients undergoing IFLT and 97 ACLF patients undergoing conventional liver transplantation (CLT). After propensity score matching (PSM), the IFLT group comprised 28 patients, while the CLT group had 51 patients. In the PSM cohort, Kaplan-Meier analysis confirmed IFLT improved patient and graft survival for ACLF patients (log rank P=0.018 and 0.018, respectively). The IFLT group demonstrated better six-month patient survival rates (100% vs 74.5%, P=0.009) and lower post-reperfusion syndrome, shorter operative time, reduced intraoperative blood loss, less blood products use. Furthermore, ACLF patients receiving IFLT experienced fewer early allograft dysfunction, reduced intensive care unit stays, earlier extubation, faster consciousness recovery, shorter time to first flatus. Accelerated recovery of liver, circulatory, respiratory, coagulation functions were observed in the IFLT group, along with fewer acute kidney injury. Notably, ACLF patients receiving ECD livers in the IFLT group achieved better survival and clinical outcomes. Consequently, IFLT enhanced the survival rates and promoted the recovery of remote organs in ACLF patients, and improved clinical prognoses for those receiving ECD livers.