Introduction:

Pediatric Liver Transplantation (PLT) continues to face significant challenges due to organ shortage and high mortality risk on the waiting list, making it increasingly difficult to maintain strict donor selection. Improving graft preservation is crucial, particularly for partial livers. Hypothermic oxygenated machine perfusion (HOPE) has emerged as a safe and straightforward preservation strategy, with growing evidence supporting its ability to improve donor liver quality in PLT.

Methods:

Prospective case series of liver grafts split and reduced ex situ using HOPE for pediatric patients (≤18 years) over 18 months (May 2024 – December 2025). Data collection included donor and recipient demographics, clinical variables, cold and warm ischemia times (CIT, WIT), operative details, HOPE preservation characteristics, and post-transplant outcomes, including complications, graft survival, and patient survival.

Results:

A total of 17 pediatric recipients (12 split, 5 reduction), with a median age of 2.9 years (1.2–7) and a median weight of 12.8 (9.2–20.3) kg. CIT was 6 hours (5–6.8), and the median HOPE duration was 4 hours (3.4–5.4), with an estimated 27% reduction in CIT with HOPE compared with our previous series. No cases of primary non-function or early ischemic-type biliary lesions were observed. Only one episode of acute rejection occurred during the first month. Cumulative patient survival was approximately 82%, whereas graft survival remained 100%.

Conclusions:

HOPE is a safe and feasible preservation strategy in PLT, including split and reduced grafts. By effectively reducing CIT, HOPE can become a standard of care for partial graft utilization in PLT.