Donation after circulatory death (DCD) organs are associated with compromised transplant outcomes and limited utilization. Normothermic regional perfusion (NRP) has been shown to significantly improve organ quality and transplant outcomes. Our group previously demonstrated the feasibility and efficacy of ischemia‐free liver implantation (IFLI) using grafts from donation after brain death. We hypothesized that NRP sequential IFLI would be feasible and effective in DCD liver transplantation. This study presents clinical case attempts that validate the viability of this hypothesis.

We report the first case of IFLI of a DCD liver following NRP. The graft was donated by a 75‐year‐old man with a total warm ischemia time of 24 min. The abdominal organs underwent 67 min of NRP. The liver was then cold‐stored in University of Wisconsin solution and transported, with a total cold ischemia time of 548 min. After back‐table preparation, the liver was subjected to 373 min of normothermic machine perfusion (NMP) before being implanted using an ischemia‐free implant technique.

Perfusion parameters, lactate clearance, and liver enzyme levels during in situ NRP indicated that the liver was transplantable. In addition, perfusion parameters, lactate clearance, and bile production during ex situ NMP fulfilled the VITTAL criteria for transplantation. The recipient was a 65‐year‐old woman with primary biliary cirrhosis. The peak post‐transplant alanine aminotransferase level was 77 U/L, and liver function normalized within 9 days after surgery. The patient recovered uneventfully, with no evidence of early allograft dysfunction or other major complications, and was discharged on day 16 post‐transplantation.

This first report demonstrates the feasibility of NRP sequential IFLI in DCD liver transplantation.

Avatrombopag has been approved for elevating platelet counts in patients with chronic liver diseases (CLDs) accompanied by thrombocytopenia (TCP). However, limited research focuses on its safety and efficacy in CLD patients during the perioperative period of liver transplantation (LT).

We retrospectively enrolled CLD patients with severe TCP who received avatrombopag during the perioperative period of LT and analyzed therapeutic efficacy, changes in platelet counts, and related adverse events. Comparisons were conducted between liver transplant recipients who received avatrombopag and those who did not use platelet‐raising drugs, focusing on intraoperative and postoperative bleeding as well as platelet transfusions.

Of 93 patients who received avatrombopag, 67 cases (72%) achieved remission, with their platelet counts increasing to over 50 × 10⁹/L without transfusion. Additionally, 38 cases (40.9%) reached platelet counts above 100 × 10⁹/L, achieving complete remission. The overall remission rate was significantly correlated with the baseline platelet counts, suggesting that individuals with higher baselines (25−50 × 10⁹/L vs. < 25 × 10⁹/L) were more likely to achieve remission (82.1% vs. 57.7%, χ² = 5.989, p = 0.014). Using propensity score‐overlap weighting to balance the baseline bias, we compared 33 liver transplant recipients who received avatrombopag to those who did not receive any platelet‐raising drugs. Recipients who used avatrombopag achieved significantly higher platelet counts both before and after propensity score‐overlap weighting ([63.76 ± 31.33] × 10⁹/L vs. [45.73 ± 16.44] × 10⁹/L, p = 0.004; [65.37 ± 38.41] × 10⁹/L vs. [42.73 ± 17.27] × 10⁹/L, p = 0.044) and required fewer intraoperative and postoperative platelet transfusions (p < 0.05). No adverse events related to avatrombopag were observed.

Avatrombopag is safe and effective for CLD patients with TCP during the perioperative period of LT, resulting in elevated platelet counts and reduced need for platelet transfusions.