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‘Back-to-base’ combined hypothermic and normothermic machine perfusion of human donor livers

Nature Protocols volume 20, pages 2151–2170 (2025)Cite this article

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Abstract

The shortage of suitable donor organs has resulted in the use of suboptimal, high-risk, extended-criteria donor (ECD) livers, which are at an increased risk of failure after transplantation. Compared with traditional static cold storage, dynamic preservation by ex situ machine perfusion reduces the risks associated with the transplantation of ECD organs. Ex situ machine perfusion strategies differ in timing (that is, speed of procurement and transport), perfusion duration and perfusion temperature. For ‘back-to-base’ protocols, the donor liver is statically cold stored during transportation to the recipient hospital (the ‘base’) and then perfused, instead of transporting the liver using a portable perfusion system. While dual hypothermic (8–12 °C) oxygenated machine perfusion (DHOPE) allows safe prolongation of preservation duration and reduces ischemia–reperfusion injury-related complications, including post-transplant cholangiopathy, normothermic machine perfusion (NMP) at 35–37 °C facilitates ex situ viability testing of both liver parenchyma and bile ducts. Here, we describe a clinical protocol for ‘back-to-base’ combined DHOPE and NMP, linked by a period of controlled oxygenated rewarming (COR), which we call the DHOPE–COR–NMP protocol. This protocol enables restoration of mitochondrial function after static ischemic preservation and minimizes both ischemia–reperfusion and temperature-shift-induced injury during the start of NMP. The NMP phase allows viability assessment before final donor liver acceptance for transplantation. Sequential DHOPE and COR–NMP may reduce the risks associated with transplantation of ECD livers and facilitate enhanced utilization, thereby helping to alleviate the organ shortage.

Key points

  • Here, the authors describe a clinical protocol for ‘back-to-base’ combined dual hypothermic oxygenated machine preservation and normothermic machine perfusion, linked by a period of controlled oxygenated rewarming.

  • This protocol minimizes both ischemia–reperfusion and temperature-shift-induced injury during the start of normothermic machine perfusion.

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Fig. 1: Positioning of the liver during machine perfusion.
Fig. 2: Machine settings for DHOPE and COR–NMP.
Fig. 3: Essential steps of the DHOPE–COR–NMP procedure.
Fig. 4: Protocol workflow.
Fig. 5: Viability criteria during normothermic machine perfusion.

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Change history

  • 10 March 2025

    In the version of this article initially published, "(ml/min" was missing after "Target flow" in Fig. 2, while in the bottom row of Table 3, the order of values was shown incorrectly, from "–0.3 to –0.5." The figure and table are amended in the HTML and PDF versions of the article.

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Author information

Author notes

  1. These authors contributed equally: Otto B. van Leeuwen, Veerle A. Lantinga.

  2. These authors jointly supervised this work: Vincent E. de Meijer, Robert J. Porte.

Authors and Affiliations

  1. Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

    Otto B. van Leeuwen, Veerle A. Lantinga, Bianca Lascaris, Adam M. Thorne, Silke B. Bodewes, Vincent E. de Meijer & Robert J. Porte

  2. Department of Anesthesiology and Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

    Maarten W. Nijsten

  3. Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, The Netherlands

    Robert J. Porte

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Contributions

O.B.v.L., V.A.L., V.E.d.M. and R.J.P. designed the protocol, wrote and critically revised the manuscript. B.L., A.M.T., S.B.B. and M.W.N. designed the protocol and critically revised the manuscript.

Corresponding authors

Correspondence to Vincent E. de Meijer or Robert J. Porte.

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Nature Protocols thanks Damiano Patrono and Renato Romagnoli for their contribution to the peer review of this work.

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Key references

van Leeuwen, O. et al. Ann. Surg. 270, 906–914 (2019): https://doi.org/10.1097/SLA.0000000000003540

van Leeuwen, O. et al. Am. J. Transplant. 22, 1658–1670 (2022): https://doi.org/10.1111/ajt.17022

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van Leeuwen, O.B., Lantinga, V.A., Lascaris, B. et al. ‘Back-to-base’ combined hypothermic and normothermic machine perfusion of human donor livers. Nat Protoc 20, 2151–2170 (2025). https://doi.org/10.1038/s41596-024-01130-8

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