LAUSR

Purpose of review The review describes recent developments in hypothermic machine liver perfusion with a special focus on underlying protective mechanisms, and the role of this perfusion technique in high-risk donor–recipient combinations. Recent findings To maximize the number of transplantable donor livers, several centres are exploring new machine preservation techniques. In this context, hypothermic machine perfusion has been recently introduced into the clinical setting of human liver transplantation, and the effect of endischemic cold liver perfusion on posttransplant complications is currently under investigation in two multicentre, randomized controlled trials. In addition, current case series demonstrated promising results regarding the protection from intrahepatic biliary complications, particularly when livers from extended criteria donors including donation after circulatory death grafts were used. Hypothermic machine perfusion may, therefore, help to push the boundaries of acceptance criteria for high-risk donor livers. Summary In this review, we, first, describe the concept of hypothermic machine liver perfusion and present results from current clinical studies. Next, we provide details of our perfusion approach step-by-step and highlight novel pathways of reperfusion injury and protection. Third, we discuss the impact of this perfusion approach in different clinical scenarios. Finally, we report on recent clinical implementations and future aspects.