The Role of Machine Perfusion for Liver Transplantation in Children

Pediatric liver transplantation (PLT) is the only lifesaving procedure for children with advanced liver disease and tumors. Despite significant progress and overall success in PLT, the field continues to face challenges due to procedural complexity across a heterogeneous age group, especially in infants and small children. Despite the use of living donor grafts, waitlist mortality remains disproportionately high in these younger patients. The unique challenges in PLT-including limited donor availability and higher risk of complications-underscore the need for improved strategies to evaluate and optimize donor liver quality before implantation. Machine perfusion has emerged as a promising tool in this context. While the benefits of hypothermic oxygenated perfusion (HOPE) for whole and partial livers have been reported with applications during and after liver split, the evidence for normothermic machine perfusion (NMP) remains scarce. Since the first report in 2019, multiple case series and clinical studies support the efficacy of HOPE in reducing early graft dysfunction, biliary complications, and graft loss after liver transplantation in children. Despite this progress, there is a pressing need for coordinated research efforts to study how HOPE and NMP affect transplant outcomes in pediatric recipients, especially when expanding split criteria or using DCD grafts, which are vital for expanding the donor pool despite the known higher risk.