BACKGROUND Primary nonfunction (PNF) is a severe complication following liver transplantation (LT), yet precise molecular biomarkers for early identification of patients at risk remain lacking, which can delay timely therapeutic intervention. MATERIAL AND METHODS Liver biopsies were collected from patients and classified into 4 groups: control, optimal graft (OG), early allograft dysfunction (EAD), and PNF. Samples were obtained at 3 time points: T0 (pre-cold perfusion), T1 (pre-reperfusion), and T2 (post-reperfusion). Isobaric tags for relative and absolute quantitation (iTRAQ) and multiple reaction monitoring (MRM) were used for proteomic analysis and biomarker verification. RESULTS Baseline characteristics of the patients showed no significant differences between groups. A total of 6505 proteins were identified in human liver samples. There were 160 differentially expressed proteins (67 upregulated and 93 downregulated) found in the PNF group compared to the control, while 54 and 36 proteins were identified in the EAD and OG groups, respectively. Ten proteins were selected for MRM verification, confirming the significant upregulation of VWF and downregulation of PRDX1, HGD, THIO, 6PGD, and HPPD, consistent with the iTRAQ results. CONCLUSIONS PRDX1, HGD, THIO, 6PGD, HPPD, and VWF were identified as candidate proteins associated with PNF and ischemia-reperfusion injury (IRI) after LT. These findings are hypothesis-generating and require validation in larger, independent cohorts to determine their potential clinical value.

BACKGROUND:Dendritic cell (DC) migration-triggered T cell activation is a pivotal event in transplant rejection. Previous studies have established a critical role of the C-type lectin receptor 2（CLEC-2）and podoplanin (PDPN) axis in regulating DC migration. We therefore hypothesized that targeting CLEC-2-PDPN axis could prolong allograft survival in mice by impairing DC migration. MATERIALS AND METHODS:Bioinformatics analysis was performed to assess differential CLEC-2 expression between allograft and isograft tissues and to identify potential associated biological processes. Bone marrow-derived dendritic cells (BMDCs) were generated from donor mice and treated with anti-CLEC-2 to inhibit CLEC-2 function. After LPS stimulation, surface expression of costimulatory molecules and MHC class II, as well as phagocytic capacity, were analyzed. Migration in response to PDPN and CCL19 gradients and the ability to stimulate T cell proliferation were evaluated using a Transwell assay. A murine skin allograft model (BALB/c to C57BL/6) was established. Then anti-PDPN was injected into recipient mice during transplantation. Graft survival was monitored, and pathological examination of grafts, flow cytometric analysis of draining lymph nodes (assessing DC migration and T cell activation/proliferation), and serum cytokine detection by ELISA were performed. RESULTS:Bioinformatics analysis revealed that CLEC-2 was significantly upregulated in the allograft group. In vitro, CLEC-2 suppression had no significant effect on the expression of costimulatory molecules or phagocytosis in dendritic cells. However, it specifically inhibited PDPN-mediated migration and suppressed T cell proliferation in the Transwell assay. Anti-PDPN treatment significantly prolonged skin allograft survival and attenuated rejection in mice. Flow cytometry revealed a reduced proportion of migratory DCs, particularly of the cDC2 subset in the draining lymph nodes of treated mice. Furthermore, both CD4 + and CD8 +T cell proliferation and activation were markedly suppressed. ELISA results showed decreased serum levels of IL-18 and IL-1β, while elevated IL-10. CONCLUSION:Targeting the CLEC-2-PDPN axis significantly prolongs murine allograft survival via the inhibiting DC migration and subsequent T-cell proliferative responses.

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: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.

Background Donation after circulatory death (DCD) organs are associated with compromised transplant outcomes and limited utilization. Normothermic regional perfusion (NRP) has been shown to significantly improve organ quality and transplant outcomes. Our group previously demonstrated the feasibility and efficacy of ischemiau2010free liver implantation (IFLI) using grafts from donation after brain death. We hypothesized that NRP sequential IFLI would be feasible and effective in DCD liver transplantation. This study presents clinical case attempts that validate the viability of this hypothesis. Methods We report the first case of IFLI of a DCD liver following NRP. The graft was donated by a 75u2010yearu2010old man with a total warm ischemia time of 24 min. The abdominal organs underwent 67 min of NRP. The liver was then coldu2010stored in University of Wisconsin solution and transported, with a total cold ischemia time of 548 min. After backu2010table preparation, the liver was subjected to 373 min of normothermic machine perfusion (NMP) before being implanted using an ischemiau2010free implant technique. Results Perfusion parameters, lactate clearance, and liver enzyme levels during in situ NRP indicated that the liver was transplantable. In addition, perfusion parameters, lactate clearance, and bile production during ex situ NMP fulfilled the VITTAL criteria for transplantation. The recipient was a 65u2010yearu2010old woman with primary biliary cirrhosis. The peak postu2010transplant alanine aminotransferase level was 77 U/L, and liver function normalized within 9 days after surgery. The patient recovered uneventfully, with no evidence of early allograft dysfunction or other major complications, and was discharged on day 16 postu2010transplantation. Conclusions This first report demonstrates the feasibility of NRP sequential IFLI in DCD liver transplantation.

Background & Aims: 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. Methods: 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). Results: 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). Conclusions: 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. Impact and implications: 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. Clinical Trials registration: chictr.org (ChiCTR-OPN-17012090).

Background. Ischemia-free liver transplantation (IFLT) is a novel approach designed to completely eliminate ischemia/reperfusion injury, whereas normothermic machine perfusion (NMP) unavoidably exposes grafts to ischemia/reperfusion injury. The study aims to evaluate postoperative complications and patient survival in IFLT compared with NMP. Methods. In this single-center retrospective cohort study, we analyzed 220 recipients with donation after brain death liver transplantation between 2017 and 2024. Propensity score matching was used for matching in a 1:1 ratio between the IFLT group and the NMP group. The primary endpoint was early allograft dysfunction (EAD), with secondary endpoints including postoperative complications, comprehensive complication index (CCI), and patient survival. Results. After propensity score matching, there were 72 patients who received IFLT and 72 who received NMP. The incidence of EAD (15.30% versus 44.40%, P < 0.001) and the CCI at 1 y posttransplant (26.74 [95% confidence interval, 20.87-32.61] versus 38.67 [95% confidence interval, 30.95-46.39], P = 0.039) in IFLT were significantly lower than in NMP. There was a higher 1-y posttransplant patients survival rate (95.57% versus 86.11%) and graft survival rate (95.57% versus 86.11%) in the IFLT group. The overall patient survival rate was significantly higher in the IFLT group than in the NMP group (hazard ratio, 0.2731; log-rank P = 0.0084). Among extended criteria donor recipients, IFLT demonstrated superior outcomes compared with NMP, with a significantly lower incidence of EAD, reduced CCI at 1 y posttransplant, and improved 1-y posttransplant patient survival. Conclusions. Among patients with end-stage liver diseases, IFLT significantly reduced EAD and improved 1-y posttransplant patient survival compared with NMP.

Acute-on-chronic liver failure (ACLF) is a life-threatening condition with high mortality. Ischemia-free liver transplantation (IFLT), a novel clinical approach avoiding ischemia-reperfusion injury, may offer significant benefits for patients with ACLF. This study included 30 patients with ACLF undergoing IFLT and 97 patients with ACLF undergoing conventional liver transplantation. After propensity score matching, the IFLT group comprised 28 patients, whereas the conventional liver transplantation group had 51 patients. In the propensity score matching cohort, Kaplan-Meier analysis confirmed IFLT improved patient and graft survival rates for patients with ACLF (log rank P = .018 and .018, respectively). The IFLT group demonstrated better 6-month patient survival rates (100% vs 74.5%, P = .009) and lower postreperfusion syndrome, shorter operative time, reduced intraoperative blood loss, and less blood product use. Furthermore, patients with ACLF receiving IFLT experienced less early allograft dysfunction, reduced intensive care unit stays, earlier extubation, faster consciousness recovery, and shorter time to first flatus. Accelerated recovery of liver, circulatory, respiratory, and coagulation functions was observed in the IFLT group, along with fewer acute kidney injuries. Notably, patients with ACLF receiving extended criteria donor livers in the IFLT group achieved better survival rates and clinical outcomes. Consequently, IFLT enhanced the survival rates and promoted the recovery of remote organs in patients with ACLF and improved clinical prognoses for those receiving extended criteria donor livers.

BackgroundIn addition to surgical technology, successful liver transplantation (LT) depends on perioperative management, which needs an effective prognostic index. Therefore, a simplified and sensitive postoperative index for adult LT should be developed.MethodsIn total, 906 patients who underwent LT were included in this cross-sectional study. Univariate analysis was used to identify the independent risk factors for recipient survival. Multivariate logistic and stepwise regression analyses were used to construct and simplify the model design. Area under the curve (AUC) and Kaplan-Meier's (K-M) analysis demonstrated superiority of the new index. The postoperative survival score (POSS) index was further simplified via restricted cubic spline (RCS) analysis. Finally, the interpretation of the long-term mortality and subgroup analyses extended the application of the POSS index.ResultsFinally, a total of five factors (donor sex, recipient body mass index (BMI), total bilirubin (Tbil), international normalized ratio (INR) and total operative time) were identified as independent risk parameters and included in our POSS index. The AUCs of the original and simplified POSS indices were 0.764 and 0.723, respectively. Patients with high scores had poor short-term survival. Our index also functioned well in predicting long-term mortality, and it was more effective for patients with hepatitis B cirrhosis or hepatocellular carcinoma (HCC).ConclusionsWe constructed a simplified and effective postoperative survival scoring index to predict short-term complications and survival in adult LT patients.

BACKGROUND:Ischemia-free liver transplantation (IFLT) prevents ischemia-reperfusion injury (IRI) and reduces IRI-related complications. In this study, we explored the protective effects of IFLT on myocardial injury after noncardiac surgery (MINS) and postoperative pulmonary complications (PPCs). MATERIALS AND METHODS:Sixty-five patients who underwent liver transplantation were enrolled in this post hoc analysis of the IFLT-DBD trial. Intraoperative pulse indicator continuous cardiac output, pulmonary artery catheter, and blood gas parameters were prospectively collected. RESULTS:The incidence of MINS did not differ between the two groups (28.1% vs. 45.5%, P = 0.147), although the peak high-sensitive troponin level was significantly lower in the IFLT group than in the conventional liver transplantation (CLT) group (0.056 ± 0.007 vs. 0.088 ± 0.016 ng/mL, P = 0.036). The incidence of PPCs was lower in the IFLT group than in the CLT group (37.5% vs. 66.7%, P = 0.019). Multivariate analysis revealed that IFLT was an independent protective factor against PPC. The median duration of ventilation was significantly shorter in the IFLT group than in the CLT group [12.5 (3.5-21.5) vs. 18 (0-69.5) hours, P <0.001]. CONCLUSION:The use of IFLT is associated with lower peak troponin T level and lower incidence of PPC.

Donation after circulatory death (DCD) organs are associated with compromised transplant outcomes and limited utilization. Normothermic regional perfusion (NRP) has been shown to significantly improve organ quality and transplant outcomes. Our group previously demonstrated the feasibility and efficacy of ischemia‐free liver implantation (IFLI) using grafts from donation after brain death. We hypothesized that NRP sequential IFLI would be feasible and effective in DCD liver transplantation. This study presents clinical case attempts that validate the viability of this hypothesis. We report the first case of IFLI of a DCD liver following NRP. The graft was donated by a 75‐year‐old man with a total warm ischemia time of 24 min. The abdominal organs underwent 67 min of NRP. The liver was then cold‐stored in University of Wisconsin solution and transported, with a total cold ischemia time of 548 min. After back‐table preparation, the liver was subjected to 373 min of normothermic machine perfusion (NMP) before being implanted using an ischemia‐free implant technique. Perfusion parameters, lactate clearance, and liver enzyme levels during in situ NRP indicated that the liver was transplantable. In addition, perfusion parameters, lactate clearance, and bile production during ex situ NMP fulfilled the VITTAL criteria for transplantation. The recipient was a 65‐year‐old woman with primary biliary cirrhosis. The peak post‐transplant alanine aminotransferase level was 77 U/L, and liver function normalized within 9 days after surgery. The patient recovered uneventfully, with no evidence of early allograft dysfunction or other major complications, and was discharged on day 16 post‐transplantation. This first report demonstrates the feasibility of NRP sequential IFLI in DCD liver transplantation.

Objective:Evaluating the safety and efficacy of implanting a liver with islet grafts into patients with end-stage liver disease and diabetes mellitus (DM).Background:DM and end-stage liver diseases are significant health concerns worldwide, often coexisting and mutually influencing each other. Addressing both diseases simultaneously is paramount.Methods:We utilized the islet transplantation combined ischemia-free liver transplantation technique to treat a patient with hepatocellular carcinoma and type 2 diabetes mellitus. The liver was procured and preserved using the ischemia-free liver transplantation technique, and during normothermic machine perfusion, isolated and purified islet grafts were transplanted into the liver through the portal vein. Finally, the liver, incorporating with the transplant islet grafts, was implanted into the recipient without interruption of blood supply.Results:The patient received both liver and islet grafts from the same donor. The patient achieved insulin-independence by post-transplant day 9, and both liver and islet function remained robust. The patient was discharged on post-transplant day 16 and experienced no surgical or transplantation-related complications during the follow-up period. Furthermore, islet grafts presence was observed in liver biopsies after islet transplantation.Conclusions:This landmark case marks the inaugural application of ischemia-free liver transplantation in humans, signifying its potential as a promising treatment modality for end-stage liver disease with DM.

OBJECTIVES:To quantify and forecast the global, regional, and national disease burden of hepatitis B virus (HBV) and hepatitis C virus (HCV)-related liver cancer attributable to high body-mass index (BMI) from 1990 to 2050. STUDY DESIGN:A global burden and projection study utilizing GBD 2021 data analysis. METHODS:Data from the Global Burden of Disease (GBD) Study 2021 were analyzed to estimate deaths, disability-adjusted life years (DALYs), and age-standardized rates (ASRs) associated with HBV/HCV-related liver cancer attributable to high BMI globally and across regions. Temporal trends from 1990 to 2021 were assessed using estimated annual percentage change (EAPC) and hierarchical cluster analysis. Forecasts for disease burden to 2050 employed Autoregressive Integrated Moving Average (ARIMA) and exponential smoothing (ES) models. RESULTS:In 2021, globally, high BMI contributed to approximately 15,698 HBV-related deaths and 17,090 HCV-related deaths, a marked increase since 1990. Burdens were higher among males, older populations, and exhibited substantial regional variations, with the greatest burden observed in China and increasing trends notable in Central Asia, Australasia, and North America. Forecasting models project a continued rise in liver cancer burden attributable to high BMI through 2050. CONCLUSIONS:The disease burden of HBV/HCV-related liver cancer attributable to high BMI has significantly increased globally and is projected to further rise. Public health initiatives integrating viral hepatitis control with obesity prevention are urgently needed to mitigate future disease burdens.

The incidence of liver diseases is on the leading rise worldwide, but there is a lack of exact research models mimic liver diseases. Using the normothermic machine perfusion (NMP) platform to study diseased livers recovered from the liver transplantation (LT) recipients seems promising. Therefore, the aim of this study was to establish the first machine perfusion system called Life-XDL to cultivate diseased liver. Four diseased livers recovered from LT recipients within different diagnoses were collected. The diseased livers were connected to the Life-XDL machine perfusion system that circulated Life-XDL perfusate providing oxygen and nutrients. The pressure and flow of the device was recorded and blood gas analysis and laboratory test of perfusate and bile was examined to analyze the function of the diseased livers. Liver tissues after perfusion were collected for histological analysis. Experiments showed that Life-XDL kept the diseased livers at the physiological state with providing stable hemodynamics and suitable partial pressure of oxygen and carbon dioxide. The results of blood gas analysis and laboratory test results demonstrated restoration and maintenance of metabolism and less damage. Moreover, the bile production of case 1, 3 and 4 diseased livers represented its vivid functionality. The pathological characteristics were kept stable before and after NMP. Overall, we successfully establish the Life-XDL machine perfusion system which specially for diseased human whole liver and develop a new diseased human whole organ model in vitro through normothermic machine perfusion that recapitulate the main features of the human liver disease, which showing great promise as disease modeling platforms.

Purpose Hepatocellular carcinoma (HCC) is one of the malignant tumors responsible for high mortality and recurrence rates. Although liver transplantation (LT) is an effective treatment option for HCC, ischemia-reperfusion injury (IRI) is a contributor to HCC recurrence after LT. Moreover, prolonged cold ischemia time (CIT) is a risk factor for IRI during LT, and there is insufficient clinical evidence regarding the impact of CIT on HCC recurrence after LT. Patients and Methods This retrospective study analyzed 420 patients who underwent LT for HCC between February 2015 and November 2020 at The First Affiliated Hospital, Sun Yat-sen University. The duration of CIT was defined as the time from clamping of the donor aorta until portal reperfusion. Results A total of 133 patients (31.7%) experienced tumor recurrence after LT, and CIT > 568 min was the independent risk factor for HCC recurrence (OR, 2.406; 95% CI [1.371–4.220]; p = 0.002). Multivariate Cox’s regression analysis revealed that the recipients’ gender, exceeding Milan criteria, poor differentiation, and alpha-fetoprotein (AFP) ≥400 ng/ml in CIT > 568 min group were independent risk factors for disease-free survival. The peak 7-day postoperative alanine aminotransferase (ALT) level (p < 0.001), the peak 7-day postoperative aspartate aminotransferase (AST) level (p < 0.001), the peak 7-day postoperative peak total bilirubin (TBIL) level (p = 0.012), and the incidence of early allograft dysfunction (EAD) (p = 0.006) were significantly higher in the CIT > 568 min group compared to the CIT ≤ 568 min group. Moreover, the amount of fresh frozen plasma (FFP) infusion during the operation increased (p = 0.02), and the time of mechanical ventilation postoperative was longer (p = 0.045). Conclusion An effective strategy to improve the prognosis is to reduce CIT; this strategy lowers the recurrence of HCC in patients undergoing LT, especially those within the Milan criteria.

Background/Aims: The shortage of donor liver hinders the development of liver transplantation. This study aimed to clarify the poor outcomes of functionally marginal liver grafts (FMLs) and provide evidence for the improvement of ischemia-free liver transplantation (IFLT) after FML transplantation. Methods: Propensity score matching was used to control for confounding factors. The outcomes of the control group and FML group were compared to demonstrate the negative impact of FMLs on liver transplantation patients. We compared the clinical improvements of the different surgical types. To elucidate the underlying mechanism, we conducted bioinformatic analysis based on transcriptome and single-cell profiles. Results: FMLs had a significantly greater hazard ratio (HR: 1.969, P =0.018) than did other marginal livers. A worse 90-day survival (Mortality: 12.3% vs. 5.0%, P =0.007) was observed in patients who underwent FML transplantation. Patients who received FMLs had a significant improvement in overall survival after IFLT (Mortality: 10.4% vs 31.3%, P =0.006). Pyroptosis and inflammation were inhibited in patients who underwent IFLT. The infiltration of natural killer cells was lower in liver grafts from these patients. Bulk transcriptome profiles revealed a positive relationship between IL-32 and Caspase 1 (R=0.73, R =0.73, P =0.01) and between IL-32 and Gasdermin D (R=0.84, R =0.84, P =0.0012). Conclusions: FML is a more important negative prognostic parameter than other marginal liver parameters. IFLT might ameliorate liver injury in FMLs by inhibiting the infiltration of NK cells, consequently leading to the abortion of IL-32, which drives pyroptosis in monocytes and macrophages. (Clin Mol Hepatol 2024;30:421-435)