Hypothermic Oxygenated Perfusion Versus Static Cold Storage in Transplantation of Extended Criteria Liver Grafts: A Systematic Review and Meta-Analysis

Abstract

Background: The use of extended criteria donor livers (ECD) is becoming more routine in many transplant centers. These organs have higher risks for complications; however, hypothermic-oxygenated perfusion (HOPE) was found to improve outcomes, including graft survival. We aim to assess the effect of HOPE on different types of ECD liver grafts. Methods: A systematic search was conducted of PubMed, EMBASE, and Cochrane databases to identify studies that compared HOPE versus static cold storage (SCS) for ECD. Subgroup analysis on ECD from brain death (DBD-ECD) and circulatory death (DCD) donors, and of randomized controlled trials (RCT) were conducted. Primary endpoints were primary non-function (PNF), early allograft dysfunction (EAD), length of ICU/hospital stay, vascular/biliary complications, retransplantation, and graft survival. Results: Twelve studies were identified comprising 1833 transplant patients (29% receiving HOPE and 71% SCS). Pooled analysis showed a significant reduction of EAD, 1-year graft failure rate, retransplantation rate, non-anastomotic biliary strictures and Clavien-Dindo Grade ≥ 3 complications favoring HOPE. Subgroup analysis on DBD-ECD grafts yielded lower EAD and shorter length of the hospital stay with HOPE. Further subgroup analysis on DCD grafts demonstrated lower EAD rates, superior 1-year graft survival rates, and reduced NAS in the HOPE group. Finally, analysis including RCTs revealed decreased EAD and retransplantation rates in the HOPE group. Conclusions: Reported outcomes after ECD liver transplantation were significantly improved with HOPE compared to SCS alone. This effect was even more pronounced in DCD grafts.