Cradle Compression During Normothermic Machine Perfusion in Liver Transplantation: Incidence and Impact on Postoperative Outcomes

BACKGROUND: Normothermic machine perfusion (NMP) has improved liver preservation, but cradle compression (CC)-a pressure-related graft injury during perfusion-remains poorly characterized. This study evaluated the incidence, risk factors, and clinical impacts of CC after NMP. METHODS: Among 145 liver transplants with NMP, 78 recipients underwent postoperative abdominal computed tomography within 30 d and were analyzed. CC was classified radiologically into grades 1-3. Postoperative outcomes, complications, and graft survival were compared by CC severity, and logistic regression was used to identify risk factors. RESULTS: CC was identified in 27 patients (34.6%): grade 1 (n = 6), grade 2 (n = 12), and grade 3 (n = 9). Patients with CC had significantly higher peak alanine aminotransferase within 7 d (2059 ± 188 versus 336 ± 83 U/L; P < 0.001), higher bilirubin and international normalized ratio at day 7, and more frequent early allograft dysfunction (61% versus 13%; P < 0.001), particularly in grade 3 CC (89%). Grade 3 CC was also associated with prolonged vasopressor use (78.4 ± 15.9 versus 10.3 ± 7.0 h; P < 0.001), longer ventilation ( P = 0.008), severe acute kidney injury (60%, all stage 3; P = 0.030), extended ICU and hospital stays ( P < 0.05), and higher Comprehensive Complication Index at discharge (50.9 ± 9.6 versus 29.1 ± 4.3; P = 0.041). Liver-related graft survival decreased with CC severity ( P = 0.036), with the poorest outcomes in grade 3. Donor age >48 y and graft weight >1900 g were independent risk factors. CONCLUSIONS: Although limited to recipients who underwent postoperative computed tomography, CC was strongly associated with adverse outcomes, especially in grade 3 cases. Donor age and graft weight were the risk factors.