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.