Liver transplantation: embracing the future with machine perfusion

Transplante de fígado: o futuro com a implementação da máquina de perfusão

Despite the annual increase in liver transplants, a persistent disparity between suitable donors and recipients continues to challenge the transplant community. The introduction of machine perfusion emerged as a novel approach to organ preservation. This technique, which utilizes extended criteria donor grafts, is expected to reduce rejection rates and expand the donor pool. Its principle, like that of any ex vivo machine perfusion, is based on the continuous supply of nutrients and oxygen to maintain cellular metabolism while interrupting anaerobic processes. This helps prevent conditions such as ischemia-reperfusion injury, early graft dysfunction, and ischemic cholangiopathy, which can lead to graft loss and the need for retransplantation. There are two main modes of ex vivo machine perfusion: hypothermic and normothermic, differentiated by the operating temperature. Utilizing ex situ perfusion machines presents a promising opportunity to increase liver graft usage and reduce waitlist times. However, it is crucial to evaluate how much this technology would raise the overall cost of transplants. In Brazil, implementing a machine perfusion program may encounter unique challenges not seen in other countries. These challenges include limited access to the healthcare system for high-risk liver transplant candidates, long waiting lists, inadequate support for organ donors, reliance solely on deceased brain-dead donors, since donation after cardiac death is not ethically accepted, and geographical barriers.

Headings:
Liver Transplantation; Transplantation; Organ Transplantation; Perfusion; Tissue and Organ Procurement

• Machine perfusion represents a revolution in organ preservation for liver transplantation.

• With over 67,000 patients on the waiting list in 2024, Brazil urgently needs new organ preservation strategies.

• Machine perfusion has the potential to save hundreds of discarded livers per year, expanding the donor pool.

• The cost of normothermic machine perfusion can be justified by increased graft utilization and reduced retransplantation rates.

CENTRAL MESSAGE  Despite the annual increase in liver transplants, the persistent disparity between suitable donors and recipients remains an ongoing issue for the transplant community. Alternatives such as extended criteria donor allografts, donors after circulatory death, and grafts with significant macrosteatosis have been employed to address this disparity. The introduction of machine perfusion in clinical practice emerged as a novel approach to organ preservation. This technique is expected to lower rejection rates and broaden the donor pool by utilizing extended criteria donor grafts.

PERSPECTIVES  The advent of the perfusion era in liver transplantation rapidly modified the landscape for the predictable future. New research and randomized controlled trials are underway to determine whether machine perfusion is a viable and superior alternative to static cold storage. It remains uncertain how costs will affect healthcare expenditures related to transplants, as machine perfusion has shown improved graft utilization and better patient outcomes. Comprehensive and standardized transplant research studies are essential to thoroughly investigate these issues and provide robust data to support the use of machine perfusion.