Background : Acute-on-chronic liver failure (ACLF) is a global epidemic in hospitalised patients with high short-term mortality. This study was performed to assess the transplant benefit of ischemia-free liver transplantation (IFLT) in patients with ACLF compared to standard liver transplantation (SLT).

Methods : In this retrospective study, 20 patients received IFLT and 92 patients received SLT were chosen for the entire cohort between July 2017 through October 2022. A 1:2 propensity score matching was performed, resulting in 20 IFLT recipients and 37 matched SLT patients in propensity-matched cohorts. Donor and recipient characteristics, intraoperative and postoperative outcome between two groups were assessed.

Results : In both the entire cohort and propensity-matched cohort, patients in the IFLT group had lower incidence of post reperfusion syndrome, faster recovery of coagulation function and consciousness, shorter fasting time, earlier extubation, and shorter intensive care unit stay. A lower incidence of early allograft dysfunction was observed in the IFLT group. Furthermore, in the propensity matched cohort, the IFLT group had lower incidence of acute kidney injury grade 3 and less application of renal replacement therapy within 14 days. No primary non-function occurred in the IFLT group, while it was 5.3% in the SLT group. Kaplan–Meier analysis showed that the 6-month and 3-year graft survival in the IFLT group were significantly higher than those in the SLT group (P=0.039).

Conclusions : IFLT largely prevents ischemia-reperfusion injury of liver grafts when performed in patients with ACLF, resulting in good transplant outcome with intraoperative stable hemodynamics, less remote organ injury and acceptable survival benefits.