Combined sequential ex vivo perfusion of liver grafts from expanded criteria donors: a contemporary perspective

Despite significant advancements in the field of liver transplantation (LT) over the last 30 years, the gold standard for allograft preservation – static cold storage with pharmacological agents – has remained largely unchanged. The growing disparity between demand for liver transplants and shortage of donor livers, along with a high wai ting list mortality rate (potentially up to 20%), has forced transplant teams to broaden donor eligibility criteria. This expansion, however, has inevitably impacted both the immediate and long-term LT outcomes. Dynamiс preservation of liver allografts has shown consistently positive outcomes, particularly among expanded criteria donors, including those classified as high-risk donors» Over the past decade, several perfusion techniques, tegrating various temperature conditions, have been developed and are under active investigation. A significant advancement in this area is the emergence of combined sequential ex vivo machine perfusion, which integrates multiple perfusion strategies. This approach leverages the strengths of each method while mitigating their in- dividual limitations. This paper reviews current experience with combined sequential ex vivo perfusion of liver grafts, providing a concise overview of the key stages encompassed within this protocol.