Liver Machine Perfusion Research Articles

Development of a Rat Liver Machine Perfusion System for Normothermic and Subnormothermic Conditions

Ex vivo liver machine perfusion (MP) is a promising alternative for preservation of liver grafts from extended criteria donors. Small animal models can be used to evaluate different perfusion conditions. We here describe the development of a miniaturized ex vivo MP system for rat liver grafts, evaluating cell-free and erythrocyte-based perfusion solutions, subnormothermic and normothermic temperatures, and dialysis. A perfusion chamber was designed after a suitable liver position was identified. Normothermic ex vivo liver perfusion (NEVLP) required supplementation of erythrocytes to reduce cell damage. Perfusion with erythrocytes led to rising potassium levels after 12 h (NEVLP, 16.2 mM, interquartile range [IQR]: 5.7 and subnormothermic ex vivo liver perfusion [SNEVLP], 12.8 mM, IQR: 3.5), which were normalized by dialysis using a laboratory dialysis membrane (NEVLP, 6.2 mM, IQR: 0.5 and SNEVLP, 5.3 mM, IQR: 0.1; p = 0.004). Livers treated with NEVLP conditions showed higher bile production (18.52 mg/h/g, IQR: 8.2) compared to livers perfused under SNEVLP conditions (0.4 mg/h/g, IQR: 1.2, p = 0.01). Reducing the perfusion volume from 100 to 50 mL allowed for higher erythrocyte concentrations, leading to significantly lower transaminases (15.75 U/L/mL, IQR: 2.29 vs. 5.97 U/L/mL, IQR: 18.07, p = 0.002). In conclusion, a well-designed perfusion system, appropriate oxygen carriers, dialysis, and miniaturization of the perfusion volume are critical features for successful miniaturized ex vivo liver MP. Impact Statement Ex vivo liver machine perfusion (MP) is an emerging preservation alternative to static cold storage. Even though clinical studies have shown benefits for extended criteria donor grafts, standardized systems for perfusion of rat liver grafts are not available, which are inevitable for large-scaled studies on liver reconditioning by ex vivo MP. We here comprehensively describe the development of an ex vivo rat liver perfusion system that can be used as modular setting in various approaches of liver MP. We describe pitfalls and techniques that might be of interest when establishing such perfusion systems for basic and translational research.

Biliary Bicarbonate, pH, and Glucose Are Suitable Biomarkers of Biliary Viability During Ex Situ Normothermic Machine Perfusion of Human Donor Livers.

Ex situ normothermic machine perfusion (NMP) can be used to assess viability of suboptimal donor livers before implantation. Our aim was to assess the diagnostic accuracy of bile biochemistry for the assessment of bile duct injury (BDI). In a preclinical study, 23 human donor livers underwent 6 hours of end-ischemic NMP to determine biomarkers of BDI. Livers were divided into groups with low or high BDI, based on a clinically relevant histological grading system. During NMP, bile was analyzed biochemically and potential biomarkers were correlated with the degree of BDI. Receiver operating characteristics curves were generated to determine optimal cutoff values. For clinical validation, identified biomarkers were subsequently included as viability criteria in a clinical trial (n = 6) to identify transplantable liver grafts with low BDI. Biliary bicarbonate and pH were significantly higher and biliary glucose was significantly lower in livers with low BDI, compared with high BDI. The following cutoff values were associated with low BDI: biliary bicarbonate greater than 18 mmol/L (P = 0.002), biliary pH greater than 7.48 (P = 0.019), biliary glucose less than 16 mmol/L (P = 0.013), and bile/perfusate glucose ratio less than 0.67 (P = 0.013). In the clinical trial, 4 of 6 livers met these criteria and were transplanted, and none developed clinical evidence of posttransplant cholangiopathy. Biliary bicarbonate, pH, and glucose during ex situ NMP of liver grafts are accurate biomarkers of BDI and can be easily determined point of care, making them suitable for the pretransplant assessment of bile duct viability. This may improve graft selection and decrease the risk of posttransplant cholangiopathy.

First Report of siRNA Uptake (for RNA Interference) During Ex Vivo Hypothermic and Normothermic Liver Machine Perfusion

First Report of siRNA Uptake (for RNA Interference) During Ex Vivo Hypothermic and Normothermic Liver Machine Perfusion

Improvement of Normothermic Ex Vivo Machine Perfusion of Rat Liver Grafts by Dialysis and Kupffer Cell Inhibition With Glycine

Normothermic ex vivo liver machine perfusion might be a superior preservation strategy for liver grafts from extended criteria donors. However, standardized small animal models are not available for basic research on machine perfusion of liver grafts. A laboratory-scaled perfusion system was developed consisting of a custom-made perfusion chamber, a pressure-controlled roller pump, and an oxygenator. Male Wistar rat livers were perfused via the portal vein for 6 hours using oxygenated culture medium supplemented with rat erythrocytes. A separate circuit was connected via a dialysis membrane to the main circuit for plasma volume expansion. Glycine was added to the flush solution, the perfusate, and the perfusion circuit. Portal pressure and transaminase release were stable over the perfusion period. Dialysis significantly decreased the potassium concentration of the perfusate and led to significantly higher bile and total urea production. Hematoxylin-eosin staining and immunostaining for single-stranded DNA and activated caspase 3 showed less sinusoidal dilatation and tissue damage in livers treated with dialysis and glycine. Although Kupffer cells were preserved, tumor necrosis factor α messenger RNA levels were significantly decreased by both treatments. For proof of concept, the optimized perfusion protocol was tested with donation after circulatory death (DCD) grafts, resulting in significantly lower transaminase release into the perfusate and preserved liver architecture compared with baseline perfusion. In conclusion, our laboratory-scaled normothermic portovenous ex vivo liver perfusion system enables rat liver preservation for 6 hours. Both dialysis and glycine treatment were shown to be synergistic for preservation of the integrity of normal and DCD liver grafts.

Pretransplant sequential hypo- and normothermic machine perfusion of suboptimal livers donated after circulatory death using a hemoglobin-based oxygen carrier perfusion solution.

Ex situ dual hypothermic oxygenated machine perfusion (DHOPE) and normothermic machine perfusion (NMP) of donor livers may have a complementary effect when applied sequentially. While DHOPE resuscitates the mitochondria and increases hepatic adenosine triphosphate (ATP) content, NMP enables hepatobiliary viability assessment prior to transplantation. In contrast to DHOPE, NMP requires a perfusion solution with an oxygen carrier, for which red blood cells (RBC) have been used in most series. RBC, however, have limitations and cannot be used cold. We, therefore, established a protocol of sequential DHOPE, controlled oxygenated rewarming (COR), and NMP using a new hemoglobin‐based oxygen carrier (HBOC)‐based perfusion fluid (DHOPE‐COR‐NMP trial, NTR5972). Seven livers from donation after circulatory death (DCD) donors, which were initially declined for transplantation nationwide, underwent DHOPE‐COR‐NMP. Livers were considered transplantable if perfusate pH and lactate normalized, bile production was ≥10 mL and biliary pH > 7.45 within 150 minutes of NMP. Based on these criteria five livers were transplanted. The primary endpoint, 3‐month graft survival, was a 100%. In conclusion, sequential DHOPE‐COR‐NMP using an HBOC‐based perfusion fluid offers a novel method of liver machine perfusion for combined resuscitation and viability testing of suboptimal livers prior to transplantation.

Application of okra extract in liver machine perfusion preservation solution

Application of okra extract in liver machine perfusion preservation solution

Gene Silencing With siRNA (RNA Interference): A New Therapeutic Option During Ex Vivo Machine Liver Perfusion Preservation

RNA interference (RNAi) is a natural process of posttranscriptional gene regulation that has raised a lot of attention culminating with the Nobel Prize in Medicine in 2006. RNAi-based therapeutics have been tested in experimental transplantation to reduce ischemia/reperfusion injury (IRI) with success. Modulation of genes of the innate immune system, as well as apoptotic genes, and those involved in the nuclear factor kappa B pathways can reduce liver injury in rodent liver pedicle clamping and transplantation models of IRI. However, in vivo use of RNAi faces limitations regarding the method of administration, uptake, selectivity, and stability. Machine perfusion preservation, a more recent alternative approach for liver preservation showing superior results to static cold preservation, could be used as a platform for gene interference therapeutics. Our group was the first to demonstrate uptake of small interfering RNA (siRNA) during liver machine preservation under both normothermic and hypothermic perfusion. Administering siRNA in the perfusion solution during ex vivo machine preservation has several advantages, including more efficient delivery, lower doses and cost-saving, and none/fewer side effects to other organs. Recently, the first RNAi drug was approved by the US Food and Drug Administration for clinical use, opening a new avenue for new drugs with different clinical applications. RNAi has the potential to have transformational therapeutic applications in several areas of medicine including transplantation. We believe that machine preservation offers great potential to be the ideal delivery method of siRNA to the liver graft, and future studies should be initiated to improve the clinical applicability of RNAi in solid organ transplantation.

Impact of Machine Perfusion on Biliary Complications after Liver Transplantation.

We describe in this review the different types of injuries caused to the biliary tree after liver transplantation. Furthermore, we explain underlying mechanisms and why oxygenated perfusion concepts could not only protect livers, but also repair high-risk grafts to prevent severe biliary complications and graft loss. Accordingly, we summarize experimental studies and clinical applications of machine liver perfusion with a focus on biliary complications after liver transplantation. Key points: (1) Acute inflammation with subsequent chronic ongoing liver inflammation and injury are the main triggers for cholangiocyte injury and biliary tree transformation, including non-anastomotic strictures; (2) Hypothermic oxygenated perfusion (HOPE) protects livers from initial oxidative injury at normothermic reperfusion after liver transplantation. This is a unique feature of a cold oxygenation approach, which is effective also end-ischemically, e.g., after cold storage, due to mitochondrial repair mechanisms. In contrast, normothermic oxygenated perfusion concepts protect by reducing cold ischemia, and are therefore most beneficial when applied instead of cold storage; (3) Due to less downstream activation of cholangiocytes, hypothermic oxygenated perfusion also significantly reduces the development of biliary strictures after liver transplantation.

First Report of siRNA Uptake During Ex Vivo Hypothermic and Normothermic Liver Machine Perfusion

First Report of siRNA Uptake During Ex Vivo Hypothermic and Normothermic Liver Machine Perfusion

Outcomes of DCD liver transplantation using organs treated by hypothermic oxygenated perfusion before implantation

Donation after circulatory death (DCD) liver transplantation is known for potentially worse outcomes because of higher rates of graft non-function or irreversible cholangiopathy. The impact of machine liver perfusion techniques on these complications remains elusive. We aimed to provide data on 5-year outcomes in patients receiving DCD liver transplants, after donor organs had been treated by hypothermic oxygenated perfusion (HOPE). Fifty HOPE-treated DCD liver transplants performed in Zurich between 2012 and 3/2017 were matched with 50 primary donation after brain death (DBD) liver transplants, and with 50 untreated DCD liver transplants in Birmingham. Match factors focussed on short cold ischaemia, comparable recipient age and low recipient laboratory model for end-stage liver disease scores. Primary endpoints were post-transplant complications, and non-tumour-related patient death or graft loss. Despite extended donor warm ischaemia, HOPE-treated DCD liver transplants achieved similar overall graft survival, compared to standard DBD liver transplants. Particularly, graft loss due to any non-tumour-related causes occurred in 8% (4/50) of cases. In contrast, untreated DCD livers resulted in non-tumour-related graft failure in one-third (16/50) of cases (p = 0.005), despite significantly (p <0.001) shorter functional donor warm ischaemia. Five-year graft survival, censored for tumour death, was 94% for HOPE-treated DCD liver transplants vs. 78% in untreated DCD liver transplants (p = 0.024). The 5-year outcomes of HOPE-treated DCD liver transplants were similar to those of DBD primary transplants and superior to those of untreated DCD liver transplants, despite much higher risk. These results suggest that a simple end-ischaemic perfusion approach is very effective and may open the field for safe utilisation of extended DCD liver grafts. Machine perfusion techniques are currently being introduced into the clinic, with the aim of optimising injured grafts prior to implantation. While short-term effects of machine liver perfusion have been frequently reported in terms of hepatocellular enzyme release and early graft function, the long-term benefit on irreversible graft loss has been unclear. Herein, we report on 5-year graft survival in donation after cardiac death livers, treated either by conventional cold storage, or by 1-2 h of hypothermic oxygenated perfusion (HOPE) after cold storage. Graft loss was significantly less in HOPE-treated livers, despite longer donor warm ischaemia times. Therefore, HOPE after cold storage appears to be a simple and effective method to treat high-risk livers before implantation.

Evolution of dynamic, biochemical, and morphological parameters in hypothermic machine perfusion of human livers: A proof-of-concept study.

IntroductionHypothermic machine perfusion (HMP) is increasingly investigated as a means to assess liver quality, but data on viability markers is inconsistent and the effects of different perfusion routes and oxygenation on perfusion biomarkers are unclear.MethodsThis is a single-centre, randomised, multi-arm, parallel study using discarded human livers for evaluation of HMP using arterial, oxygen-supplemented venous and non-oxygen-supplemented venous perfusion. The study included 2 stages: in the first stage, 25 livers were randomised into static cold storage (n = 7), hepatic artery HMP (n = 10), and non-oxygen-supplemented portal vein HMP (n = 8). In the second stage, 20 livers were randomised into oxygen-supplemented and non-oxygen-supplemented portal vein HMP (n = 11 and 9, respectively). Changes in dynamic, biochemical, and morphologic parameters during 4-hour preservation were compared between perfusion groups, and between potentially transplantable and non-transplantable livers.ResultsDuring arterial perfusion, resistance was higher and flow was lower than venous perfusion (p = 0.001 and 0.01, respectively); this was associated with higher perfusate markers during arterial perfusion (p>0.05). Supplementary oxygen did not cause a significant alteration in the studied parameters. Morphology was similar between static and dynamic preservation groups. Perfusate markers were 2 fold higher in non-transplantable livers (p>0.05).ConclusionsArterial only perfusion might not be adequate for graft perfusion. Hepatocellular injury markers are accessible and easy to perform and could offer insight into graft quality, but large randomised trials are needed to identify reliable quality assessment biomarkers.

Factors predicting viability achievement on discarded donor livers submitted to extra-corporeal machine perfusion

Introduction: Ex-vivo machine perfusion of livers (MP) may offer superior preservation for marginal donor organs. During normothermic machine perfusion (NMP) is possible to assess liver viability before transplantation. A period of hypothermic machine perfusion (HMP) prior to NMP may restore the liver metabolism. The aim of this study was to compare viability criteria achievement in livers subjected to NMP-only or a combination of HMP followed by NMP; and, analyse factors associated with the positive outcome. Methods: We analysed 46 discarded human livers submitted to MP including NMP alone for 6 hours or a combined protocol of HMP for 2 hours followed by NMP for further 4 hours. Viability was assessed at the end of the NMP in both groups using the lactate clearance criteria. Results: Steatosis was the main for organ discard (46%). 24/46 (52%) organs achieved viability criteria. From 29 livers that had NMP-only 12 (41%) met viability compared to 12 (71%) from the 17 livers submitted to the combined protocol (p=0.050). Non-viable livers had higher donor BMI (p=0.048) and liver weight (p=0.011) and were discarded more often for steatosis (p=0.001). On multivariable analysis livers declined for steatosis (OR:50.6; 95%CI:3.7-688.9; p=0.003), donor height (OR:1.1; 95%CI:1.1-1.2; p=0.039) and NMP alone (OR:10.3; 95%CI:1.5-70.9; p=0.018) were independent risk factors for non-achievement of the viability criteria. Conclusion: Combination of HMP and NMP can increase the rescue of very-high risk extended criteria donor livers. However steatosis remains the major risk factor for non-viability achievement. New strategies to improve those organs still needed.

Perfusion settings and additives in liver normothermic machine perfusion with red blood cells as oxygen carrier. A systematic review of human and porcine perfusion protocols.

Liver machine perfusion (MP) at normothermic temperature (NMP) is a promising way to preserve and evaluate extended criteria donor livers. Currently, no consensus exists in methodology and perfusion protocols. Here, the authors performed a systematic literature search to identify human and porcine studies reporting on liver NMP with red blood cells. A qualitative synthesis was performed concerning technical aspects of MP, fluid composition, gas supply, and liver positioning. Thirty-seven publications including 11 human and 26 porcine studies were considered for qualitative synthesis. Control mode, pressure, flow, perfusate additives, and targeted blood gas parameters varied across human as well as porcine studies. For future analyses, it is advisable to report flow adjusted to liver weight and exact pressure parameters including mean, systolic, and diastolic pressure. Parenteral nutrition and insulin addition was common. Parenteral nutrition included amino acids and/or glucose without lipids. Taurocholic acid derivatives were used as bile flow promoters. However, short-term human NMP without taurocholic acid derivatives seems to be possible. This finding is relevant due to the lack of clinical grade bile salts. Near physiological oxygen tension in the perfusate is doable by adjusting gas flows, while blood gas parameters regulation needs more detailed description.

The Synthesis Of Coagulation Factors During Normothermic Machine Perfusion Of Livers Is Impaired By Ischemia In Pigs And Might Predict Graft Viability

Normothermic Machine Perfusion (NMP) of livers is a promising tool to test graft viability during preservation. Coagulation factors are synthetized by the liver, hence are candidate markers of function. We evaluated the production of coagulation factors during NMP, tested if ischemia alters their synthesis, and correlated their levels with markers of hepatocyte damage (AST) and sinusoidal endothelial injury {Hyaluronic acid (HAc)}. Method Porcine livers exposed to 60 min Warm Ischemia (WI60, n=5) or not (WI0, n=5) were NMP perfused for 6 h. The concentration of Factors V (FV), VIII (FVIII), and X (FX) in the perfusate was measured at 15, 30min, 1, 2, 3, and 6h of NMP and compared within and between groups (between-within ANOVA). Levels of AST and HAc were correlated to FV and FVIII. Mean ±SD is given. Results FV increased significantly over time in both groups, although with a different kinetics, as a plateau was reached at 2h of NMP in WI0 only. FV concentration was inferior in WI60 vs. WI0 (p<0.0001) (Figure 1A). Similarly, FVIII raised over time significantly in both WI0 and WI60, reaching a plateau at 3h of NMP only in WI0. The production of FVIII was inferior in WI60 vs. WI0 (p=0.006) (Figure 1B). FX raised steadily without a plateau in WI0, while no significant increase was observed in WI60, in which the concentration of FX was inferior (p=0.001) (Figure 1C). The area under the curve of AST was greater in WI60 (3077) vs WI0 (405.3, p=0.0006). FV was inversely correlated to AST release at all time points except 6h. HAc levels increased over time [11.3 ±5.3 ng/mL at 15min to 101.8 ±75.5 ng/mL at 6h in WI0 (p=0.045), and from 51.5 ±6.9 ng/mL at 15min to 303.2 ±107.7 ng/mL at 6h in WI60 (p=0.01)] and were higher in WI60 vs WI0 (p=0.004). FVIII was inversely correlated to HAc levels at 1h (r:-0.58, p=0.02) and 2h (r:-0.59, p=0.03) of NMP. Discussion Coagulation factors are actively produced during NMP and their synthesis was impaired during NMP of severely WI damaged porcine livers. In particular, FV and FVIII, produced by hepatocytes and sinusoidal cells, respectively, can be used as markers of function of the hepatocellular and endothelial compartment, since they were inversely related to markers of hepatocellular injury (AST) and sinusoidal cell damage (HAc). FX synthesis during NMP should be further investigated, since its production is dependent on vitamin K, which was not supplemented in the perfusion system. The correlation of our findings to post-transplant outcomes warrants further investigations. Conclusion The production of coagulation factors during NMP of human livers and their role in the assessment of viability deserve to be explored.

The Intestinal-Liver Axis of FGF15-FGFR4-PPARα Signal Control Liver Ischemia Reperfusion Injury Through Regulating Autophagy

Background The hallmarks of liver ischemia/reperfusion (I/R) injury, a common clinical problem that occurs during liver transplantation, include severe cell death that contributes to early graft failure. Emerging evidence indicates that the liver-intestine signal fibroblast growth factor 15 (FGF15)-fibroblast growth factor receptor 4 (FGFR 4) plays a critical regulatory role in liver physiology/pathology. FGF15 is secreted in the ileum and binding to FGFR4 in liver. However, the role of FGF15-FGFR4 signal in liver I/R injury remains unknown. Methods and Results Quantitative immunohistochemistry for 243 cases human donor liver biopsy at 1 hour after reperfusion showed that the FGFR4 expression significantly correlates with higher early allograft dysfunction and poor long term survival of liver transplantation recipients. In mice 70% liver I/R model, serum FGF15 and liver FGFR4 expression were 6-fold and 5-fold upregulated at 72 hour of reperfusion, respectively. Pharmacological inhibition by BLU9931 or genetic knock out of FGFR4 could protect liver injury through upregulating autophagy, and subsequently reduce mitochondrial dysfunction and endoplasmic reticulum stress. We then demonstrated FGFR4 could transcriptional down regulate autophagy by inhibition of PPARα during reperfusion. Through CHIP-seq data we identified that PPARα promoted transcription of autophagy genes (Atg3 and Atg7) by directly binding to their promoter. Knockdown either Atg3 or Atg7 abolished protective effect of BLU9931 on I/R injury. Finally in ex vivo porcine liver machine perfusion model, we confirmed that infusion Fgf15 recombinant protein aggravate liver I/R injury by inhibition of PPARα and subsequently autophagy. Conclusion This study uncovers the intestinal and liver cross talk (FGF15-FGFR4-PPARα signal) as a key role regulating liver I/R. The potently and selectively FGFR4 inhibitor BLU9931 may be used as a promising agent to ameliorate liver I/R.

Implementing an innovated preservation technology: The American Society of Transplant Surgeons' (ASTS) Standards Committee White Paper on Ex Situ Liver Machine Perfusion.

The pervasive shortage of deceased donor liver allografts contributes to significant waitlist mortality despite efforts to increase organ donation. Ex vivo liver perfusion appears to enhance preservation of donor organs, extending viability and potentially evaluating function in organs previously considered too high risk for transplant. These devices pose novel challenges for organ allocation, safety, training, and finances. This white paper describes the American Society of Transplant Surgeons' belief that organ preservation technology is a vital advance, but its use should not change fundamental aspects of organ allocation. Additional data elements need to be collected, made available for organ assessment by transplant professionals to allow determination of organ suitability in the case of reallocation and incorporated into risk adjustment methodology. Finally, further work is needed to determine the optimal strategy for management and oversight of perfused organs prior to transplantation.

The dawn of liver perfusion machines.

Despite high demand, a severe shortage of suitable allografts limits the use of liver transplantation for the treatment of end-stage liver disease. The transplant community is turning to the utilization of high-risk grafts to fill the void. This review summarizes the reemergence of ex-vivo machine perfusion for liver graft preservation, including results of recent clinical trials and its specific role for reconditioning DCD, steatotic and elderly grafts. Several phase-1 clinical trials demonstrate the safety and feasibility of machine perfusion for liver graft preservation. Machine perfusion has several advantages compared with static cold storage and may provide superior transplantation outcomes, particularly for marginal grafts. Ongoing multicenter trials aim to confirm the results of preclinical and pilot studies and establish the clinical utility of ex-vivo liver machine perfusion. Mounting evidence supports the benefits of machine perfusion for preservation of liver grafts. Thus, machine perfusion is a promising strategy to expand the donor pool by reconditioning and assessing viability of DCD, elderly and steatotic grafts during the preservation period. Additionally, machine perfusion will serve as a platform to facilitate graft intervention and modification to further optimize marginal grafts.

Donation after Circulatory Death in Paediatric Liver Transplantation: Current Status and Future Perspectives in the Machine Perfusion Era.

Efforts have been made by the transplant community to expand the deceased donor pool in paediatric liver transplantation (LT). The growing experience on donation after circulatory death (DCD) for adult LT has encouraged its use also in children, albeit in selective cases, opening new perspectives for paediatric patients. Even though there has recently been a slight increase in the number of DCD livers transplanted in children, with satisfactory graft and patient outcomes, the use of DCD grafts in paediatric recipients is still controversial due to morbid outcomes associated with DCD grafts. In this context, recent advances in the optimization of donor support by extracorporeal membrane oxygenation and in the graft preservation by liver machine perfusion could find application in order to expand the donor pool in paediatric LT. In the present study we review the current literature on DCD liver grafts transplanted in children and on the use of extracorporeal donor support and liver perfusion machines in paediatrics, with the aim of defining the current status and future perspectives of paediatric LT.

Fundamental study of metabolism in liver machine perfusion to evaluate the organ function before transplantation

Fundamental study of metabolism in liver machine perfusion to evaluate the organ function before transplantation

Mechanisms of autophagy activation in endothelial cell and their targeting during normothermic machine liver perfusion.

Ischaemia-reperfusion injury (IRI) is the leading cause of injury seen in the liver following transplantation. IRI also causes injury following liver surgery and haemodynamic shock. The first cells within the liver to be injured by IRI are the liver sinusoidal endothelial cells (LSEC). Recent evidence suggests that LSEC co-ordinate and regulates the livers response to a variety of injuries. It is becoming increasingly apparent that the cyto-protective cellular process of autophagy is a key regulator of IRI. In particular LSEC autophagy may be an essential gatekeeper to the development of IRI. The recent availability of liver perfusion devices has allowed for the therapeutic targeting of autophagy to reduce IRI. In particular normothermic machine liver perfusion (NMP-L) allow the delivery of pharmacological agents to donor livers whilst maintaining physiological temperature and hepatic flow rates. In this review we summarise the current understanding of endothelial autophagy and how this may be manipulated during NMP-L to reduce liver IRI.