Machine perfusion in liver transplantation: A step forward, but still on the runway

The recent editorial by Parente et al provides a balanced overview of machine perfusion (MP) in liver transplantation. While its potential to improve graft preservation is clear, several challenges hinder routine adoption: High costs, logistical complexity, lack of standardized viability criteria, limited long-term outcome data, and absence of direct comparisons between hypothermic and normothermic MP. From my experience of over 900 liver transplants without MP, and the limited uptake among Korean centers, compelling evidence for its necessity remains lacking. The immunomodulatory effects of MP, particularly in ABO-incompatible or sensitized recipients, remain underexplored. Future research should integrate immune profiling, mechanistic analyses, and biomarker-guided immunosuppression strategies into multicenter trials to clarify its role in tolerance induction and long-term graft protection. Ethical, regulatory, and policy considerations especially in resource-limited settings must also be addressed to ensure equitable access. Robust clinical and mechanistic data are essential before MP can be fully endorsed as standard care.