Extended criteria donors (ECDs) have an impact on early allograft dysfunction (EAD), biliary complications, relapse of hepatitis C virus (HCV), and survivals. Early allograft dysfunction was frequently seen in grafts with moderate and severe steatosis. Donors after cardiac death (DCD) have been associated with higher rates of graft failure and biliary complications compared to donors after brain death. Extended warm ischemia, reperfusion injury and endothelial activation trigger a cascade,

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... ng to microvascular thrombosis, resulting in biliary necrosis, cholangitis, and graft failure. The risk of HCV recurrence increased by donor age, and associated with using moderately and severely steatotic grafts. With the administration of protease inhibitors sustained virological response was achieved in majority of the patients. Donor risk index and EC donor scores (DS) are reported to be useful, to assess the outcome. The 1-year survival rates were 87% and 40% respectively, for donors with a DS of 0 and 3. Graft survival was excellent up to a DS of 2, however a DS >2 should be avoided in higher-risk recipients. The 1, 3 and 5-year survival of DCD recipients was comparable to optimal donors. However ECDs had minor survival means of 85%, 78.6%, and 72.3%. The graft survival of split liver transplantation (SLT) was comparable to that of whole liver orthotopic liver transplantation. SLT was not regarded as an ECD factor in the MELD era any more. Full-right-full-left split liver transplantation has a significant advantage to extend the high quality donor pool. Hypothermic oxygenated machine perfusion can be applied clinically in DCD liver grafts. Feasibility and safety were confirmed. Reperfusion injury was also rare in machine perfused DCD livers. I) Introduction As discussed earlier, extended criteria donors are used widely. In this chapter a review is given about the impact of ECD on the outcome. Living related liver transplantation is discussed shortly, whether the partial grafts can still be regarded as ECD or not. Machine perfusion, as a possible management was also reviewed briefly. Outcome parameters are divided as possible complications, and survival results. Complications are listed as early graft dysfunction, biliary complications, HCV recurrence. Survival rates are summarized separately. Split, and living related LT discussed briefly, and finally the machine perfusion, as a possible future aspect is summarized. Downloaded by [Debrecen University] at 23:56 01 February 2016 II) Complications 1) Early graft dysfunction (initial poor function, or delayed graft function) ECD donors are also not optimal for candidates with a high MELD score. Briceno et al reported their prediction for graft dysfunction based on ECD-scores and MELD score. In their findings ECD 2 (relative risk [RR]=1.59; 95% confidence interval [CI]=1.25-1.62), ECD 3 (RR=2.74; 95% CI=2.38-3.13), as well as MELD 21 to 30 (RR=1.89; 95% CI=1.32-2.06), and MELD more than or equal to 30 (RR=3.38; 95% CI=2.43-3.86).were independent risk factors for IPF or PNF. In summary they state that a combination of ECD>3 and MELD >29 is the worst scenario [1]. A similar report was published by Palmiero et al about 1786 OLTs. ECD criteria were the same as described earlier. The predictive factors for death among the whole population were DRI >1.5, cold ischemia time ≥9 hours, MELD ≥25, female recipient, and longer waiting list time [2]. Silberhummer et al figured out the recipients' condition by the delta-MELD: as the difference between the MELD at transplantation and the MELD at listing. Patients with a both delta-MELD>1 and an ECD>2 together had a higher chance to develop EAD, and also significantly higher risk for mortality [3] . Others report a similar incidence of EAD, PNF, acute rejection, biliary complication and also that ECD had no significant effect on either ICU stay or duration of postOLT ventilation, and also the postOLT laboratory test, bleeding, biliary and vascular complication rates were similar in ECD and non-ECD groups, and finally the rate of IPF was 27% vs 31% in ECD and non-ECD grafted patients [4] . There was no difference (P = .882) in total hospital stay and ICU stay (P = .788) among recipients having three or more extended criteria, and also renal replacement therapy was necessary in a similar proportion in all these groups (P = .783) [5] . Grafts with mild steatosis can be safely used in OLT with risk of postoperative EAD compared to non-steatotic grafts, if other risk factors are excluded [6, 7] . The long-term outcome is also good. Grafts with moderate macrovesicular steatosis (30-60%) may be utilized in the absence of additional risk factors in the donor or recipient; livers with more than 60% macrosteatosis should Downloaded by [Debrecen University]