Abstract
Background/Objectives: Liver transplantation (LT) remains the standard treatment for end-stage liver disease. While donation after brain death (DBD) is the predominant source of grafts, non-standard donors are increasingly used. Optimizing procurement techniques may improve graft function and reduce early allograft dysfunction (EAD). Methods: This retrospective monocenter study analyzed 231 first LT performed between 2013 and 2024. Patients were divided into two eras: Era 1 (n = 143, 2013-2019, standard aortic perfusion) and Era 2 (n = 88, 2019-2024, refined procurement strategies including combined aortic-portal perfusion, adjusted perfusion volumes, and additional caval venting). Exclusion criteria were retransplantation, DCD, split grafts, combined transplants, and early thrombosis. The primary endpoint was EAD. Secondary endpoints included graft loss and mortality. Stabilized inverse probability of treatment weighting (IPTW) was applied to balance groups. Results: After IPTW, EAD incidence was significantly reduced in Era 2 (42.3% vs. 24.6%, p < 0.0001). Similarly, graft loss (12.6% vs. 32.2%, p < 0.0001) and mortality (11.6% vs. 30.8%, p < 0.0001) decreased. Kaplan-Meier analysis showed improved graft survival in Era 2 (HR = 0.52, 95%CI: 0.28-0.99, p = 0.046). Sub-analysis of expanded criteria donors confirmed significant reductions in EAD, graft loss, and mortality. Conclusions: Refined procurement strategies in DBD grafts significantly reduced EAD, graft loss, and mortality. These simple, cost-effective refinements represent a valuable approach to optimize outcomes, particularly with marginal donors, and warrant validation in multicenter prospective studies.