Comparative Analysis of Short-Term Outcomes of Hypothermic Oxygenated Machine Perfusion Versus Static Cold Storage in Deceased Donor Liver Transplantation: A Single-Centre Experience

Introduction: Liver transplantation treats end-stage liver disease, but deceased donor organ scarcity drives use of extended criteria donors with higher ischemia-reperfusion injury risks. Hypothermic oxygenated machine perfusion (HOPE) restores mitochondrial function and reduces complications versus static cold storage (SCS), per international trials. India faces unique challenges: low deceased donation rates (0.8/million), prolonged cold ischemia from logistics, and resource constraints. This study provides the first matched HOPE-SCS comparison from South India.
Methods: Retrospective matched cohort study of 32 adult DDLT recipients (HOPE n=16, SCS n=16) at Apollo Main Hospital, Chennai (Jan 2023-Dec 2025). 1:1 matching balanced donor/recipient factors. HOPE used Liver Assist device (portal vein perfusion, 4-10°C, 60-120 min, oxygenated Belzer MPS). SCS used UW on ice. Primary outcome was to find early allograft dysfunction and secondary outcomes : ΔMAP% at reperfusion, surgical/biliary complications, acute rejection, day 7 biochemistry, ICU/hospital stay, 30-/90-day survival. Statistics were perfomed based on following : t-test/Mann-Whitney U, chi-square/Fisher's exact, Kaplan-Meier (p<0.05 significant).
Results: Baseline donor and recipient profiles were broadly similar, although donor risk index was significantly lower in the HOPE group (1.14±0.08 vs 2.09±0.18, p<0.001). Despite longer cold and total ischemia times in HOPE, these grafts exhibited markedly better intraoperative hemodynamic stability, with ΔMAP% 4.2±2.1% versus 26.2±5.3% in SCS (p<0.001). HOPE was associated with significantly fewer surgical complications (31.2% vs 81.2%, p=0.013), less bleeding requiring intervention (37.5% vs 81.2%, p=0.012), and a striking reduction in biopsy-proven acute rejection (6.2% vs 50.0%, p=0.006). EAD incidence was lower with HOPE (43.8% vs 62.5%), although this difference was not statistically significant (p=0.479), and day 7 liver function tests were comparable between groups. Ninety-day survival favored HOPE (93.8% vs 75.0%, p=0.330), with one death in HOPE (sepsis) versus four in SCS (three sepsis, one acute liver failure), though survival differences did not reach statistical significance in this limited sample.

Conclusion: In this single-centre Indian cohort, HOPE preservation was associated with substantially improved intraoperative hemodynamic stability, fewer surgical complications and bleeding events. While reductions in EAD and improvements in early survival did not achieve statistical significance, the consistent direction and magnitude of benefit support HOPE as a promising preservation strategy for DDLT in resource-constrained environments with challenging logistics and increasing use of marginal grafts. These data represent the first comparative HOPE experience from India and highlight the potential of HOPE to enhance the safety and utilization of deceased donor livers; larger multicentre prospective studies with longer follow-up are warranted to confirm these findings and evaluate cost-effectiveness in the Indian healthcare setting.