Combined machine perfusion and ischemia-free implantation of livers from high-risk donors: fi rst experience in Russia

Objective: to assess the effi cacy and safety of combining sequential dual hypothermic oxygenated machine perfusion (DHOPE), controlled oxygenated rewarming (COR), and normothermic machine perfusion (NMP) with ischemia-free liver implantation (IFLI) for transplants obtained from high-risk expanded criteria donors (ECDs). Materials and methods . The study presents two cases of liver transplantation performed using the combined DHOPE-COR-NMP-IFLI protocol in May and June 2025 at the Shumakov National Medical Research Center of Transplantology and Artifi cial Organs. Liver allografts were procured from brain-dead ECDs. Perfusion was carried out using a cardiopulmonary bypass (CPB) machine following a period of static cold storage (SCS). The allografts were subsequently transplanted into recipients under continuous NMP after meeting viability criteria. The reproducibility and safety of the IFLI approach within the combined protocol were evaluated through descriptive analysis of donor characteristics, perfusion parameters, and intra- and postoperative outcomes in the recipients. Results . In both cases, the grafts met the established viability criteria despite pronounced macrovesicular steatosis (95% and 80%, respectively). In Case No. 1, all viability parameters were achieved after 4 hours of NMP. In Case No. 2, lactate clearance was suboptimal, reaching the acceptable threshold of 4.1 mmol/L only after 6 hours of perfusion. No post-perfusion syndrome or hemodynamic instability occurred in either recipient during graft reperfusion. Both recipients met the criteria for early allograft dysfunction, with cytolysis levels of 6562.9 and 1610.4 U/L, and 3822 and 2662 U/L, respectively. The recipients were discharged on postoperative days 17 and 34 without serious complications (Clavien–Dindo ≥IIIb). At 4- and 5-month follow-up, no transplant- or preservation-related complications were observed. Conclusion . The combined application of sequential machine perfusion (DHOPE-COR and NMP) with IFLI is a safe and eff ective dynamic preservation strategy. This approach enables the successful use of liver grafts from ECDs by minimizing ischemia–reperfusion injury.