Machine Perfusion Plus for Extended Criteria Donor Liver Grafts: Making Every Liver Count

Transplantation represents the most effective treatment for end-stage liver diseases but is limited by the shortage of healthy donor organs. Extended criteria donor (ECD) liver grafts are increasingly utilized in clinical practice to mitigate this challenge. However, impaired ischemic tolerance of these grafts jeopardizes organ viability during cold storage. Machine perfusion (MP) was designed to improve organ preservation and reduce posttransplant complications. Nevertheless, it is increasingly evident that MP alone may not preserve ECD grafts optimally. Increasing emphasis has thus been placed on modified MP strategies, including the use of different perfusates, modified perfusion modalities, and different therapeutic interventions. Here, we introduce a novel term, “MP Plus,” denoting these additional strategies that are designed to restore organ function and potentially enable regeneration of ECD grafts. In this review, we summarize the existing and potential modified MP strategies and discuss their advantages in reconditioning different ECD grafts in clinical settings.