Ischemia-free Liver Transplantation Improves Long-term Outcomes in a 5-Year Follow-up Study

Ischemia-free liver transplantation (IFLT) is a novel technique designed to avoid ischemia-reperfusion injury (IRI). Here, we report the first detailed 5-year follow-up outcomes. We conducted a cohort study comparing long-term outcomes between IFLT and conventional liver transplantation (CLT) recipients of livers donated after brain death (DBD). The primary objective was to evaluate 5-year patient and graft survival. Additional endpoints included graft loss, biliary complications, rejection, infections, and liver-related laboratory tests. Subgroup analysis was performed to validate the generalizability of the results in patients with pre-transplant hepatocellular carcinoma (HCC). A total of 168 patients were enrolled, with 38 patients in the IFLT group and 130 patients in the CLT group. Five-year patient survival (86.84% vs. 56.92%; hazard ratio [HR] 0.246, 95% confidence interval [CI] 0.098-0.620; p <0.01) and graft survival (84.61% vs. 56.92%; HR 0.307, 95% CI 0.131-0.719; p <0.01) rates were significantly improved in the IFLT group compared with the CLT group. In the multivariate analysis, IFLT emerged as an independent protective factor for 5-year patient survival (HR 0.246, 95% CI 0.098-0.620; p <0.01). Conversely, HCC before transplantation (HR 2.039, 95% CI 1.159-3.590; p <0.05), donor age (HR 1.022, 95% CI 1.001-1.040; p <0.05), and extended criteria donor (HR 2.088, 95% CI 1.215-3.590; p <0.01) were identified as independent risk factors for impaired 5-year patient survival. In patients with pre-transplant HCC, the 5-year overall survival rate of the IFLT group was also significantly higher than that of the CLT group after adjustment for HCC risk factors (82.35% vs. 42.03%; HR 0.249, 95% CI 0.074-0.831; p <0.05). Long-term (5-year) follow-up data demonstrate that the use of IFLT potentially improves both patient and graft survival, when compared with CLT, in transplantation of brain-dead donor livers. Ischemia-free liver transplantation (IFLT) has emerged as a new approach designed to avoid IRI throughout all episodes of the transplant procedure. It has been confirmed that the use of IFLT can substantially reduce early-onset graft IRI-related complications. In this first 5-year follow-up study on the IFLT technique, we demonstrate that, compared with conventional liver transplantation, IFLT can potentially improve long-term patient and graft survival by reducing cancer recurrence. This new technique has the potential to change current clinical practice, particularly in the use of marginal grafts and in patients with HCC. chictr.org (ChiCTR-OPN-17012090).