Optimizing liver utilization for transplantation with partial grafts undergoing normothermic machine perfusion: Two case reports.

Background: Liver transplantation (LT) is the only curative, life-saving option for children and adults with end-stage liver disease. Due to the well-known shortage and heterogeneity of grafts, split LT (SLT) is an attractive strategy to expand the donor pool and reduce waitlist times. Given increased risk of cold ischemia time with SLT, machine perfusion represents a promising option to reduce it and optimize transplant logistics and outcomes. The present communication describes various possible combinations of procurement steps to perform SLT facilitated by placing one or both grafts on a normothermic machine perfusion (NMP) closed circuit device.

Case summary: A 19-month-old female with biliary atresia after failed Kasai portoenterostomy and a 42-year-old woman with unresectable intrahepatic cholangiocarcinoma were selected as recipients for a SLT from a 17-year-old male donor. The SLT generated a left lateral segment and a right trisectional graft of appropriate volume for both recipients. After a mixed in-situ and ex-situ split, in order to improve logistics, the right trisectional graft was placed on a closed circuit NMP device, following an appropriate vascular reconstruction. Both grafts were implanted with excellent short-term outcomes.

Conclusion: Use of NMP with SLT for preservation prior to implantation allows not only for graft optimization but also for significant improvement of transplant logistics. We propose various models and standardization of logistic options for combining SLT with NMP to optimize graft availability and outcomes.