End-ischemic HOPE rescue of declined liver grafts after prolonged static cold storage: Three cases with 6-year graft survival

Prolonged preservation time is a major risk factor for graft dysfunction in liver transplantation, particularly when extended criteria donor (ECD) grafts are used. Hypothermic oxygenated machine perfusion (HOPE) has emerged as a promising preservation strategy for marginal grafts by improving mitochondrial function and limiting ischemia-reperfusion injury. We report 3 cases of liver transplantation performed using ECD grafts that had been declined by other transplant centers and arrived at our institution after prolonged static cold storage (SCS). In all cases, grafts underwent end-ischemic ex vivo HOPE before implantation. SCS time was 14, 13, and 11 hours, respectively, whereas HOPE time was 3, 6, and 5 hours, resulting in total preservation times of 17, 19, and 16 hours. All grafts were successfully transplanted, with satisfactory early graft recovery and no early allograft dysfunction or primary non-function. The recipients were discharged 15, 14, and 17 days after transplantation, respectively. At a median follow-up of 6 years, all recipients were alive with functioning grafts and without biliary complications, infectious complications, or HCC recurrence. These cases suggest that ex vivo HOPE may represent a useful post-conditioning strategy for selected ECD liver grafts exposed to prolonged preservation in challenging logistical settings.