Ischemia-free liver transplant (IFLT) has been developed to reduce ischemia-reperfusion injury (IRI). This study aims to investigate how this procedure impacts local and systemic immunity compared to conventional liver transplantation (CLT). Immunohistochemistry, immunofluorescence staining, single-cell RNA sequencing (scRNA-seq), and multiplex cytokine are used to illustrate distinct local and systemic immunity. In contrast to CLT, IFLT reduces neutrophil infiltration and neutrophil extracellular trap formation in grafts. By constructing an immune cell chimerism atlas, we reveal that IFLT reduces recipient-derived monocyte infiltration by suppressing ANXA1-FPR1 signaling through the STAT3-HIF-1α pathway, thereby attenuating inflammatory responses in graft monocytes. Additionally, IFLT confers graft protection by upregulating HMOX1 expression in monocytes and macrophages. Peripherally, IFLT significantly reduces the expression of MHC II molecules in circulating monocytes. Accordingly, CD8+ effector T cell composition, T helper 1 (Th1) and Th17 cytokine levels are reduced, while regulatory T cell (Treg) composition and Th2 cytokine levels are increased in IFLT versus CLT recipients. These results show that IFLT profoundly affects local and systemic immunity in liver transplantation. Recipient-circulating monocytes might play a key role in the interaction between graft IRI and allograft rejection.

The persistent disparity between organ donation rates and clinical demand has driven the increasing use of extended-criteria donor livers. However, conventional static cold storage inadequately preserves extended-criteria donor with severe ischemia-reperfusion injury (IRI), contributing to high rates of mortality and morbidity. Although different machine perfusion technologies have been used to reduce IRI in clinical practice, organ ischemia remains unavoidable throughout the entire transplantation procedure. To minimize IRI to the greatest extent possible, we developed a novel ischemia-free liver transplantation (IFLT) method based on surgical innovation and continuous normothermic machine perfusion. IFLT not only effectively preserves graft quality but also expands the donor pool, making it possible to utilize high-risk livers. Classic IFLT increases the complexity of donor liver procurement and prolongs the anhepatic phase during implantation. Here we develop a simplified IFLT (SIFLT) technique. By streamlining the donor liver retrieval procedure and optimizing the sequence of vascular anastomosis during implantation, the efficacy and safety data for SIFLT are comparable to those of classic IFLT, with similar rates of postoperative complications, graft survival and patient survival. Thus, SIFLT represents a more efficient, safer and widely applicable approach to minimize organ ischemia, offering a robust strategy to improve outcomes and maximize organ utilization.

Background: Tumor recurrence is associated with poor post-operative survival for patients with hepatocellular carcinoma (HCC), which can be promoted by ischemia-reperfusion injury (IRI) during liver transplantation. Ischemia-free liver transplantation (IFLT) can largely abrogate IRI by avoiding graft ischemia. This study aimed to evaluate whether IFLT can improve patient survival in HCC patients by reducing the risk of cancer recurrence. Methods: This retrospective cohort study included adult patients with HCC who underwent primary liver transplantation using donation-after-brain-death (DBD) grafts between July 2017 and December 2024. Patient survival and incidence of HCC recurrence were compared between IFLT and conventional liver transplantation (CLT).Causal mediation analysis was performed to evaluate the extent to which differences in HCC recurrence contributed to the survival difference between the IFLT and CLT groups. Findings: A total of 400 patients were included, comprising 68 in the IFLT group and 332 in the CLT group. IFLT was associated with a higher 5-year survival probability than CLT (adjusted HR 0·440, 95% CI 0·229-0·847, p = 0·014). The cumulative incidence of HCC recurrence was also lower in the IFLT group than in the CLT group (SHR 0·465, 95% CI 0·236-0·916, p = 0·027). Mediation analysis showed that reduced tumor recurrence accounted for 71·8% of the 5-year survival benefit of IFLT over CLT. The oncological and survival benefits were more significant in patients beyond Milan or UCSF criteria. Interpretation: IFLT is associated with improved 5-year patient survival in patients with HCC, which is mainly mediated by reduced tumor recurrence post-transplantation. These associations might be more pronounced in patients with HCC beyond Milan or UCSF criteria. Funding: The study was supported by the National Natural Science Foundation of China (82170663, 82370664, 82300744, W2511088 and 82525012); Guangdong Provincial Key Laboratory Construction Projection on Organ Donation and Transplant Immunology (2023B1212060020); Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation) (2020A0505020003); Science and Technology Program of Guangdong (2024B1515040011, 2024A1515013030).

BACKGROUND:The liver is essential for coagulation-anticoagulation balance. Ischemia-free liver transplantation (IFLT) has been proven to prevent ischemia-reperfusion injury (IRI) and improve postoperative recovery. In this study, we explored protective effects of IFLT on the coagulation system. MATERIALS AND METHODS:Sixty-five liver transplant patients were enrolled in this post hoc analysis of the IFLT-DBD (ischemia-free transplantation of livers from donors after brain death) trial. Data of blood loss, blood product transfusion, intraoperative conventional coagulation tests, and rapid thromboelastography were evaluated. Transcriptome analysis was performed, and liver tissue specimens were collected for experimental validation. RESULTS:Total blood loss was significantly lower in the IFLT group than in the conventional liver transplantation (CLT) group [1765.0 (565.0-2965.0) vs 2600.0 (595.0-4605.0) mL, P<0.001]. The IFLT group had fewer red blood cells (RBC), fresh frozen plasma (FFP), and platelet (PLT) transfusions than the CLT group [RBC: 4 (2-6) vs 7.25 (2.25-8) units, P = 0.026; FFP: 600 (0-600) vs 600 (400-987.5) ml, P = 0.031; PLT: 6(18.8%) vs 13(39.4%), P = 0.026]. Bulk transcriptome analysis showed that hepatocyte nuclear factor 4 alpha (HNF4α) expression was higher in the IFLT group. Real-time PCR revealed higher mRNA expression of HNF4α, factor II, and V in the IFLT group. Western blotting showed higher HNF4α protein expression in the IFLT group. CONCLUSION:Adopting IFLT significantly decreased intraoperative hemorrhage and blood product transfusion. IFLT facilitates the restoration of intraoperative coagulation homeostasis by preserving the HNF4α-mediated regulation of hepatic coagulation factor synthesis.

ABSTRACT Background Immune checkpoint inhibitors (ICIs) have shown promise in downstaging hepatocellular carcinoma (HCC) for liver transplantation (LT), enabling previously ineligible patients to meet transplant criteria. However, their use raises concerns about post‐transplant acute rejection (AR) based on data lacking information regarding standardized management pathways and notably perioperative protocols, including immunosuppression protocols and monitoring. Methods This study evaluated 59 LT recipients divided into three groups (two control groups), including 13 ICI‐exposed patients (third group). All groups followed a standardized immunosuppression protocol and monitoring embedded into an enhanced recovery after surgery (ERAS) protocol, featuring basiliximab and steroid induction, early mammalian target of rapamycin inhibitor (mTOR) use, and reduced tacrolimus dosing. Results Despite varied ICI washout intervals (median 36 days), no AR episodes were observed in any group. One‐year overall survival and recurrence‐free survival were 93%/85% and 100%/85% in standard patients, and 77%/69% in ICI‐exposed patients, respectively. The most frequent complications were biliary and infectious, with no significant intergroup differences. Conclusions These findings suggest that in a standardized clinical pathway with structured immunosuppressive protocols, therapeutic drug monitoring, and early complication surveillance, LT can be safely performed after ICI exposure without increasing rejection risk. The study underscores the need for standardized clinical pathways and consistent reporting of immunosuppressive regimens to optimize outcomes in this emerging patient population.

There is increasing clinical evidence for the protective effect of the hypothermic oxygenated perfusion (HOPE) treatment strategy in human donation after circulatory death (DCD) liver transplantation. HOPE treatment is routinely applied for 2 hours after static cold storage (SCS). This study aimed to determine the optimal timing and duration of HOPE treatment by comparing different HOPE treatment strategies in a porcine DCD liver transplantation model. Donor livers from Tibetan miniature pigs underwent 60-minute warm ischemia and were then randomized into 4 groups according to different preservation strategies, including SCS treatment, upfront HOPE (U-HOPE), end-ischemic HOPE (E-HOPE), and continuous HOPE (C-HOPE) treatment groups (n = 6 per group). All these livers were transplanted orthotopically. Posttransplant survival and graft ischemia-reperfusion injury were assessed during a 7-day follow-up. The 7-day survival rates were 0% for the SCS treatment group, 33.3% (2/6) for the U-HOPE treatment group, and 100.0% (6/6) for both E-HOPE and C-HOPE treatment groups. Compared with the SCS treatment strategy, all HOPE treatment strategies enhanced lactate clearance and liver function recovery, reduced oxidative stress and inflammatory responses, reduced hepatocellular and biliary injury, and protected mitochondrial function. Importantly, such protective effects were more pronounced in the livers undergoing E-HOPE and C-HOPE treatments than in U-HOPE treatments. All HOPE treatment approaches showed superior preservation of DCD livers over SCS. Among them, the E-HOPE and C-HOPE treatments achieved improved short-term survival and enhanced protection against graft ischemia-reperfusion injury in comparison with the U-HOPE treatment.