Machine perfusion in liver transplantation: A step forward, but still on the runway

Table 1 Comparative features of hypothermic vs normothermic machine perfusion strategies in liver transplantation

Parameter	Hypothermic MP (HOPE/D-HOPE)	Normothermic MP
Metabolic activity	Suppressed; reduces oxygen demand and cellular stress	Maintained; mimics physiological conditions
Viability assessment	Limited; lacks dynamic functional readouts	Real-time assessment via lactate clearance, bile output, etc.
Biliary protection	Strong evidence for reduced ischemic biliary injury	Mixed results; less consistent protection
Immunomodulatory potential	Underexplored; minimal data on immune modulation	Emerging evidence of Treg induction, cytokine shifts
Logistical complexity	Relatively simple; lower equipment and staffing requirements	More complex; requires specialized devices and trained personnel
Cost	Lower; fewer consumables and infrastructure needs	Higher; expensive devices and perfusate components
Clinical integration	Increasing use, especially in Europe and for marginal grafts	Growing adoption; more common in viability-guided protocols
Limitations	No active metabolism; limited therapeutic intervention window	Risk of overinterpretation of viability markers; cost barriers

MP: Machine perfusion; HOPE: Hypothermic oxygenated perfusion; D-HOPE: Dual hypothermic oxygenated perfusion; Treg: Regulatory T cell.