Progress of machine perfusion in managing donor-derived infections in liver transplantation

Donor-derived infection (DDI), particularly when involving multidrug-resistant organisms (MDROs), represents a formidable barrier in liver transplantation, contributing significantly to high graft discard rates amid the global organ shortage. Conventional static cold storage (SCS) remains inadequate for infected grafts, as it lacks the capacity for dynamic functional assessment or targeted therapeutic intervention, frequently necessitating the exclusion of these high-risk organs. Machine perfusion (MP) has emerged as a transformative strategy, preserving liver grafts under physiological conditions while effectively mitigating ischemia-reperfusion injury (IRI). Beyond its preservation benefits, the integration of antibiotic therapy into MP platforms facilitates a conceptual shift toward active ex vivo pharmacologic decontamination. By leveraging continuous vascular flow, MP enhances intrahepatic antibiotic delivery efficiency and distribution uniformity, creating a potent anti-infective barrier that suppresses microbial proliferation and reduces pathogen-induced inflammation, all while avoiding the systemic toxicity associated with conventional drug administration. Despite this promise, clinical implementation faces hurdles, including the absence of standardized perfusion protocols, delayed diagnostic turnaround times, and concerns regarding potential hepatotoxicity from high-dose antibiotics. Future progress hinges on the integration of rapid diagnostic technologies like metagenomic sequencing and the development of novel anti-infective agents. Ultimately, precision antimicrobial management via MP offers a viable pathway to transform infection-exposed livers from marginal to safely transplantable resources, thereby expanding the donor pool and improving recipient outcomes.