Machine Perfusion in Liver Transplant from Marginal Donors: Current Practices and Future Directions

With the rising incidence of chronic liver disease and a persistent imbalance between organ supply and demand, expanded criteria donors (ECD) are gaining recognition. High-risk donor livers, meeting ultra-long criteria, are increasingly utilized to bridge the gap between organ demand and supply. For these high-risk livers, dynamic preservation through machine perfusion can mitigate post-transplant complications by enhancing graft quality and enabling viability testing prior to transplantation. Ex situ machine perfusion has overcome the limitations of traditional static cold preservation, transforming liver transplantation by reducing ischemia-reperfusion injury, offering a continuous assessment of organ quality, and optimizing the use of marginal grafts, thereby expanding the donor liver pool. This review summarizes current clinical applications and classifications of machine perfusion devices and explores potential future strategies for assessing the viability of marginal livers, therapeutic interventions, and organ function modulation post-recovery.