Prolonged Dual Hypothermic Oxygenated Machine Perfusion for Daytime Liver Transplant

Importance: Liver transplants are performed around the clock, often associated with substantial disutility for patients and clinicians. While short-duration dual hypothermic oxygenated machine perfusion (short-DHOPE) mitigates ischemia-reperfusion injury and related complications, prolonged DHOPE (DHOPE-PRO) may further extend preservation time and facilitate daytime liver transplant. Objective: To assess whether the use of DHOPE-PRO is associated with an increased proportion of daytime liver transplants without compromising graft or patient outcomes. Design, Setting, and Participants: This prospective cohort study conducted at a large academic liver transplant center in the Netherlands included adult and pediatric recipients of liver grafts received from donation after brain death (DBD), donation after circulatory death (DCD), or living donors. The study compared all liver transplants performed between January 1, 2023, and December 31, 2024, following routine DHOPE-PRO implementation, with a control cohort of all consecutive liver transplants performed between January 1, 2021, and December 31, 2022. Follow-up continued through December 31, 2025. Outcomes were stratified by graft type. Exposures: Grafts underwent DHOPE-PRO, with or without viability assessment depending on graft risk, or short-DHOPE (for DCD livers) or no perfusion (for DBD livers). Main Outcomes and Measures: The primary outcome was the difference in the percentage of daytime liver transplants, defined as surgery starting at or after 8 am and either (1) reperfusion occurring before 8 pm or (2) completion by midnight, between the 2021-2022 and 2023-2024 cohorts. Secondary outcomes included 1-year patient and graft survival, intraoperative parameters, and postoperative complications, stratified by graft type. Results: A total of 330 liver transplants (median [IQR] age, 45 [13-62] years; 186 [56.4%] male) were included in the analyses: 155 transplants in the 2021-2022 cohort and 175 transplants in the 2023-2024 cohort. Following DHOPE-PRO implementation, the percentage of daytime transplants increased from 48.4% (75 of 155) to 84.6% (148 of 175) for reperfusion (P < .001) and from 53.5% (83 of 155) to 89.1% (156 of 175) for completion (P < .001). Median (IQR) DHOPE duration increased from 2.1 (1.6-4.1) to 10.2 (5.1-13.1) hours (P < .001), with total preservation times up to 31.4 hours. Use of DHOPE-PRO showed no association with postoperative complications (eg, new-onset acute kidney injury; odds ratio, 0.64 [95% CI, 0.37-1.07]; P = .09]). One-year patient survival exceeded 90% in all subgroups. Use of DHOPE-PRO was not associated with either graft (hazard ratio, 1.28 [95% CI, 0.59-2.74]; P = .53) or patient (hazard ratio, 2.05 [95% CI, 0.75-5.59]; P = .16) survival. Conclusions and Relevance: In this prospective cohort study, routine implementation of DHOPE-PRO was associated with increased proportions of daytime liver transplants and with improved surgical logistics. It was also associated with outcomes similar to those after short-duration DHOPE, supporting its broader application in clinical practice.