Many advantages have been reported with the use of machine perfusion (MP) to rescue extended criteria donor (ECD) liver grafts, improving post-liver transplantation (LT) outcomes. Acute kidney injury (AKI) is a common complication associated with these grafts and may impact outcomes and increase costs.
This study analyzed post-liver transplant AKI incidence in recipients of MP-treated grafts compared with conventionally cold-stored (SCS) grafts, before and after propensity score matching (PSM). From January 2022 to May 2025 177 LTs were included: 30 MP and 147 SCS. The MP group showed more marginal characteristics: older age (72 vs. 62 years), higher proportion of DCD grafts (10% vs. 0), and more frequent macrosteatosis (≥30%). Post-liver transplant AKI rates were similar between groups (63% vs. 45.6%), with comparable stage distribution. After PSM (based on donor risk index, macrosteatosis, and recipient NaMELD score, 3:1 ratio), characteristics were balanced and AKI incidence remained similar (58.6% vs. 47.1%). Multivariate analysis identified donor diabetes and recipient age as independent predictors of AKI. Additionally, MCP-1 and TNF-α levels measured in the perfusate early during perfusion positively correlated with post-LT creatinine peak. Overall, MP remains a valuable strategy for rescuing ECD grafts, providing postoperative renal outcomes comparable to SCS despite the use of more marginal donors.