Hypothermic-Oxygenated Perfusion (HOPE) In Paediatric Liver Transplantation: Beyond Graft Preservation, Facilitating Safer Surgeries in a Donor-Limited Environment

Background: Paediatric Liver Transplantation (PLT) increasingly faces a landscape of limited and suboptimal donor grafts, alongside a rising proportion of complex recipients. Hypothermic-Oxygenated Perfusion (HOPE) mitigates ischaemia-reperfusion injury and may support graft function in this context. Aim: To evaluate feasibility and outcomes of backbench HOPE in complex PLT, compared with a historical cohort of Static Cold Storage (SCS). Methods: Prospective cohort of 22 PLT recipients who received a HOPE-perfused liver graft between September 2024 and December 2025, compared with a historical cohort of 32 PLT recipients transplanted after SCS. Variables: donor/recipient/graft characteristics, surgical complexity markers, postoperative complications and survival outcomes. Results: Recipients in both groups had a similar baseline profile, but HOPE group showed a trend towards greater surgical complexity, with longer hepatectomy times (2.3 vs. 2.1 hours, p=0.002). CIT was shorter (5.8 [5.1–6.7] vs.8 [6.8–9.1] hours; p<0.001). Median HOPE perfusion was 4.1 hours. 77% of the grafts were reduced/split on HOPE. Postoperative complications, did not differ significantly between groups, and no biliary strictures occurred in the HOPE group compared with five in the SCS group. At one year, although patient survival was numerically lower in the HOPE group (77.3% vs. 90.6%, p=0.200), all deaths occurred with functioning graft; and death-censored graft survival (95.5% vs. 96.8%, p=0.880) was comparable. Conclusions: In a donor-limited environment with complex recipients, routine backbench HOPE showed graft outcomes and survival comparable to a historical SCS group. These findings suggest a potential role for HOPE beyond graft preservation, supporting surgical synchronisation in complex PLT.