Protective value of ischemia-free liver transplantation on post-transplant acute kidney injury.
Zhao, Q., et al.JHEP Reports : Innovation in Hepatology / EASL 2025; 7(4): 101339.
Aims
To determine whether ischemia-free liver transplantation (IFLT) reduces the incidence and severity of acute kidney injury (AKI) after liver transplantation compared with conventional liver transplantation (CLT).
Interventions
Ischemia-free liver transplantation: continuous in situ to ex situ to in situ normothermic machine perfusion (NMP) maintaining uninterrupted oxygenated blood supply through portal vein, hepatic artery, and caval inflow/outflow during procurement, preservation, and implantation; compared with standard CLT using static cold storage and conventional implantation.
Participants
188 adult primary liver recipients
Outcomes
The primary was the Incidence and KDIGO stage of post-LT AKI (Stages 1–3). Secondary Outcomes: severe AKI (SAKI; Stages 2–3), AKI persistence (>48 h), need for renal replacement therapy within 7 days, perioperative creatinine trajectory, EAD, peak ALT/AST, mortality, ICU/hospital LOS, ventilator time, 1- and 3-month survival.
Follow-up
90 days
CET Conclusions
The authors have conducted a large single-centre retrospective analysis of IFLT vs CLT with propensity matching, demonstrating significant benefit of IFLT in reducing significant AKI (Stage-3 AKI: 3.2% IFLT vs 16.0% CLT, p=0.003) and early allograft dysfunction (EAD: 8.5% vs 44.7% p<0.001), as well as In-hospital death (0% vs 9.6% p=0.003). In their multivariant analysis, IFLT independently associated with lower odds of Stage-3 AKI (OR 0.166; 95% CI 0.028–0.979; p=0.047), and use of ECD liver independently increased this risk (OR 10.796; 95% CI 1.914–60.895; p=0.007). The renoprotective effect of IFLT persisting in higher-risk ECD grafts is a clinically important finding given expanding use of marginal donors. Their study is limited by the nonrandomised design, single-centre experience, potential selection biases (surgical candidacy, learning curve), and relatively short (3-month) survival follow-up; thus causal inference remains uncertain and external validity is undetermined. Still, effect sizes for severe AKI endpoints are large and consistent, suggesting that attenuating IRI via continuous perfusion may translate into clinically meaningful kidney protection after LT, particularly for ECD grafts. This technique is onerous, requiring significant surgical and technological input beyond even standard NMP, and has therefore not been investigated in many places. If there is confirmation in prospective multicentre RCTs and cost–benefit analyses demonstrate it is of value, then exploration of this technique in other countries would be useful.
Trial registration
ChiCTR2400081755