Real-World Analysis of Hypothermic Oxygenated Perfusion and Normothermic Machine Perfusion in Liver Transplantation

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OBJECTIVE: To report real-world data on hypothermic oxygenated perfusion (HOPE) and normothermic machine perfusion (NMP) in liver transplantation (LT). SUMMARY BACKGROUND DATA: Real-world comparisons between HOPE and NMP are limited and methodologically challenging due to heterogeneity in donor and recipient risk profiles and regional differences in practice patterns. METHODS: This international cohort study analyzed consecutive NMP-preserved LTs performed at 15 predominantly North American centers between 2021 and 2025. Outcomes were compared with the European HOPE-REAL cohort, comprising HOPE-treated LTs from 22 centers between 2012 and 2021. Risk-adjusted analyses were performed, stratified by graft type and risk category. Imbalances in baseline characteristics were addressed using entropy balancing. RESULTS: A total of 954 NMP-treated and 1202 HOPE-treated grafts were analyzed, revealing substantial differences in donor risk. Extended-criteria DBD grafts accounted for 30% versus 64%, and futile DCD grafts for 10% versus 30%, in the NMP and HOPE cohorts, respectively. In the NMP cohort, death-censored graft survival at 1, 2, and 3 years exceeded 96% for DBD grafts and 94% for DCD grafts. Comparable outcomes were observed in the HOPE cohort, with 93% survival in DBD and 87% in DCD grafts at up to 3 years, despite significantly higher donor risk in the HOPE-DCD cohort. After risk adjustment, death-censored graft survival remained similar between both modalities across graft types and risk categories. CONCLUSIONS: Real-world data on HOPE-treated and NMP-treated LT demonstrate excellent outcomes. Nevertheless, compared with HOPE, further high-quality evidence and longer preservation time is needed to substantiate the clinical benefits of NMP in high-risk grafts.

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