Rescue of a Discarded Liver Graft Through Viability Assessment Using Normothermic Ex Vivo Machine Perfusion

Organ shortage remains a major limitation in liver transplantation, particularly in regions with low donation rates. Marginal grafts, such as those with severe steatosis, are frequently discarded due to the high risk of primary graft dysfunction. Normothermic machine perfusion (NMP) has emerged as a strategy to enable functional assessment and expand the donor pool. Case presentation: We report the case of a 60-year-old donor liver with 70% macrovesicular steatosis and prolonged cold ischemia time (11 hours), initially considered unsuitable for transplantation. A sequential dynamic preservation strategy was implemented, consisting of dual hypothermic oxygenated perfusion (D-HOPE) followed by normothermic ex vivo machine perfusion using the Liver Assist® platform. After 2 hours of NMP, viability criteria were met, including lactate clearance (0.5 mmol/L), adequate bile production (16 mL), and favorable perfusate and bile pH values. The graft was successfully transplanted into a 58-year-old recipient with metabolic dysfunction-associated liver disease and hepatocellular carcinoma. Postoperative evolution was favorable, without graft-related complications. At one-year follow-up, both graft and patient survival were preserved. Conclusion: This case illustrates that normothermic ex vivo machine perfusion, within a dynamic preservation strategy, can enable the safe utilization of liver grafts initially deemed unsuitable. Its implementation may expand organ availability, optimize clinical decision-making, and improve outcomes, particularly in settings with a limited donor supply.