For people waiting for a liver transplant, access to a suitable donor organ can determine whether treatment arrives in time. At Sir Charles Gairdner Hospital, recent introduction of liver machine perfusion technology has changed the landscape of Western Australia, increasing liver transplantation access to recipients who could otherwise deteriorate whilst waiting for a suitable donor organ. Whilst this technology has existed elsewhere, the program in Western Australia is unique, which is an Australian first of its kind. As a result, liver transplantation rates have doubled since its introduction in June 2025.

Why donor liver assessment matters

Traditionally, a donated liver is preserved in a cold solution during transport. Cooling slows cellular activity, but it does not provide the oxygen needed to sustain normal metabolism. Injury can develop during the period without an adequate oxygen supply and again when blood flow is restored.

The difficulty is deciding which higher-risk organs can still function well after transplantation. Machine perfusion mitigates this risk, allowing an opportunity to support the liver outside the body and observe how it performs before making the final decision to transplant.

The technology utilised in WA combines cold oxygenated perfusion (HOPE) with warm (normothermic) oxygenated perfusion, with a controlled rewarming process when transitioning between the two. In contrast, existing programmes in other centres would utilise a single perfusion technology.

Cold perfusion supports recovery

During hypothermic oxygenated perfusion, cold, oxygen-rich preservation fluid circulates through the liver. The low temperature limits its energy requirements while oxygen supports recovery of mitochondrial function. Mitochondria are the structures within cells that produce usable energy.

This stage helps reduce injury associated with restoring the circulation. It can also reduce bile duct complications, which are a particular concern with livers donated after circulatory death. The aim is to improve the condition of the organ; it does not mean that every injury can be reversed or every liver is made suitable for transplantation.

Warm perfusion allows functional testing

Normothermic perfusion supplies oxygenated blood-based fluid at approximately body temperature, allowing the liver to resume metabolic activity. We can then assess its function directly. Measurements such as lactate clearance and acid–base balance help show how well the liver is working.

Bile production and bile chemistry provide further information about the biliary system. This matters because reassuring liver-cell function does not necessarily establish that the bile ducts are healthy. Assessment therefore considers several findings together, alongside donor and recipient factors. It is important to remember that meeting viability criteria supports a clinical decision; it does not guarantee an uncomplicated transplant.

What this means for patients

The purpose is to make better use of donated organs while maintaining careful selection. For patients with advanced liver disease or selected liver cancers, a larger pool of usable livers may improve the opportunity to receive a transplant before their condition deteriorates.

Introducing the programme has been a team effort, encompassing liver transplant surgeons, liver physicians, intensivists, anaesthetists, donor coordination teams (DonateLife), Theatre staff. Ultimately however, It is the organ donors and their families that make this work possible, whilst machine perfusion gives transplant teams another way to make the most of that gift.

Written by Dr Arul Suthananthan – Consultant Hepatopancreaticobiliary and Liver Transplant Surgeon

Dr Suthanathan is a Consultant Hepatopancreaticobiliary and Liver Transplant Surgeon, practicing in Western Australia (Sir Charles Gairdner Hospital, Western Australia).

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