Background: The Italian Score for Organ Allocation (ISO), a transplant benefit oriented allocation system, was introduced in Italy in 2016. The main objective of this study is to identify risk factors for Drop-Out in hepatocellular (HCC) patients enlisted for LT before (Pre-ISO Era) and after ISO (ISO Era) introduction, while the secondary objective is to evaluate the survival results. Methods: CIFs for liver transplantation and Drop-Out were estimated and compared between eras. Factors associated with Drop-Out were identified through multivariable competing risks regression. Survival results were compared using the log-rank test. Results: Between 2011 and 2020, 410 patients with HCC were listed for LT. We observed 103 vs. 217 LT and 49 vs. 41 Drop-Outs (p < 0.001) during the Pre-ISO and ISO Era, respectively. In the multivariable analysis, ISO ([sHR] 0.43; 95%CI 0.28–0.66, p < 0.001) and Alcoholic Cirrhosis ([sHR] 0.27, 95%CI 0.11–0.70; p = 0.007) were revealed to be protective factors for Drop-Out. One year after listing, the CI for Drop-Out decreased from 13.2% to 6.2% (p = 0.02). Despite no differences observed in post-LT survival, a significant difference in the intention-to-treat survival from enlisting was found (p = 0.0019). Conclusions: Among other factors, ISO results were protective for the Drop-Out risk in HCC patients awaiting LT, with a benefit in ITT-OS survival.

Graft-to-recipient weight ratio (GRWR) is widely used to guide graft selection in living donor liver transplantation (LDLT); however, its role as an independent predictor of postoperative outcomes and small-for-size syndrome (SFSS) remains debated. Graft inflow modulation (GIM) has been increasingly adopted to allow the safe use of smaller grafts. This study evaluated the impact of GRWR and GIM on short-term outcomes using data from a prospective international registry. An analysis of prospectively collected data from the International Living Donor Liver Transplant Registry (LDLTregistry.org) was conducted, including 1944 consecutive LDLT procedures performed at 55 centers (September 2023 to February 2025). Recipients were stratified by GRWR (0.80%). Primary outcomes included major postoperative complications (Clavien–Dindo ≥3a), SFSS, and 90-day mortality. Lower GRWR was associated with higher rates of major complications, SFSS, and GIM use. Overall SFSS incidence, classified according to the ILTS–iLDLT–LTSI Consensus Conference Guidelines, was 36.9%, grade B in 17.0%, and grade C in 4.0%. SFSS of any grade increased progressively with lower GRWR: 33.4% in GRWR >0.80%, 43.7% in GRWR 0.60%–0.80%, and 63.1% in GRWR <0.60% ( p <0.001). Grade A SFSS was similar across groups ( p =0.12), whereas clinically significant SFSS (grades B and C) was highest in the GRWR < 0.6% group (47.6%, p <0.001). In all, 90-day mortality remained low (<5%) across all groups. Nearly half of small grafts were unexpectedly small, without worse short-term outcomes. On multivariable analysis, GRWR was not associated with major complications. GRWR influences short-term outcomes after LDLT but does not fully explain SFSS risk, which appears multifactorial. These findings support a shift away from graft size as the sole determinant of risk, toward a physiology-based, lobe-specific, and standardized intraoperative approach in LDLT.

Background: The advent of machine perfusion (MP) has significantly improved post‐liver transplantation (post‐LT) outcomes, potentially enabling the use of increasingly marginal grafts and expanding the organ donor pool. Methods: We present a retrospective cohort study of consecutive adult patients who underwent LT between 2018 and 2023 at a leading Italian institution. The objective was to evaluate outcomes following the use of hypothermic oxygenated perfusion (HOPE) in high‐risk grafts. Results: A total of 507 patients were included in the final analysis, of whom 420 (83%) received extended criteria donor (ECD) grafts. Among ECD grafts, 62 (15%) were from donation after circulatory death (DCD) donors, and 64 (15%) were previously discarded by other centers. HOPE was applied in 248 (49%) cases. Recipients in the HOPE group experienced significantly lower rates of early allograft dysfunction (EAD) (20% vs. 32%, p = 0.007), primary nonfunction (2% vs. 7%, p = 0.017), and severe postoperative complications (Clavien–Dindo grade ≥ 3b) (19% vs. 28%, p = 0.026). Notably, marginal grafts treated with HOPE achieved survival outcomes comparable to those of standard risk. Conclusions: HOPE is associated with improved outcomes in LT using ECD grafts and can enable the safe use of higher‐risk organs with acceptable results when performed in experienced centers.