HYPOTHERMIC OXYGENATED PERFUSION (HOPE) IN LIVER TRANSPLANTATION: COMPARATIVE OUTCOMES OF DUAL-HOPE VERSUS PORTAL-HOPE AND HOPE VERSUS NORMOTHERMIC MACHINE PERFUSION

Introduction: Hypothermic oxygenated perfusion (HOPE) improves liver transplant outcomes from both donation after brain death (DCD) and circulatory death (DCD) and is widely used in Italy. Two protocols are applied: dual-HOPE (arterial and portal perfusion) and portal-HOPE (portal perfusion only). The latter avoids hepatic artery cannulation, and preclinical studies suggest adequate perfusion of the peribiliary plexus via the portal vein alone. Normothermic machine perfusion (NMP) is another preservation modality that restores full liver metabolism. However, comparative clinical data remain scarce. This retrospective study aimed to compare dual-HOPE and portal-HOPE, as well as HOPE and NMP, across multiple centres. Methods: We analysed consecutive HOPE cases from 13 Italian centres. A comparator group of NMP cases was obtained from 2 US centres. A 1:1 propensity score matching (PSM) was applied to balance donor and recipient characteristics, as well as preservation times. We then compared 90-day survival and complications (with a 12-month follow-up for biliary complications) between groups. Results: From 677 cases (2015–2023), the PSM selected 112 dual-HOPE and 112 portal-HOPE cases. Hepatic artery thrombosis was slightly higher in dual-HOPE, not significant (7.1% vs. 1.8%, p=0.106). Biliary complications, including non-anastomotic strictures, were similar (3.6% vs. 0.9%, p=0.738). Post-reperfusion syndrome (PRS) was more frequent in portal-HOPE (39.6% vs. 14.6%, p<0.001) but did not affect post- transplant course or renal function. A second 1:1 PSM matched 198 DBD and 82 DCD grafts treated with HOPE to an equal number treated with NMP. In the DCD cohort, despite longer warm ischemia, HOPE was significantly associated with fewer anastomotic (7.3% vs. 22%, p = 0.008) and non-anastomotic (5% vs. 15%, p = 0.035) biliary complications. Conclusions: Dual-HOPE and portal-HOPE are safe and comparable. Portal-HOPE shows higher PRS incidence without impacting post-transplant outcomes. Compared with NMP, HOPE appears to reduce anastomotic and non-anastomotic biliary complications in DCD grafts.