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Background: Early allograft dysfunction (EAD) affects outcomes in liver transplantation (LT). Existing risk models developed for deceased-donor LT depend on posttransplant factors and fall short in living-donor LT (LDLT), where pretransplant evaluations are crucial for preventing EAD and justifying the donor's risks., Methods: This retrospective study analyzed data from 2944 adult patients who underwent LDLT at 17 centers between 2016 and 2020. We developed a logistic regression model to predict EAD based on this development cohort. We used data from 1020 patients at the King Faisal Transplant Center for external validation., Results: In the development cohort, 321 patients (10.9%) experienced EAD. These patients had poorer health status, more liver decompensation, and higher requirements of hospitalization than those without EAD. Multivariable logistic regression identified independent pretransplant predictors of EAD: laboratory Model for End-Stage Liver Disease score (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.06-1.09), the necessity for hospitalization at the time of transplant (OR, 2.58; 95% CI, 2.00-3.30), and graft weight in kilogram (OR, 0.27; 95% CI, 0.17-0.45). Using these predictors, we developed the model for EAD after LDLT, which demonstrated strong discriminative ability in the development cohort with an area under the curve (AUC) of 0.71 (95% CI, 0.68-0.74). The model maintained high discrimination during internal validation (AUC, 0.70; 95% CI, 0.67-0.73) and showed a modest reduction in discriminative power in external validation (AUC, 0.65; 95% CI, 0.61-0.68)., Conclusions: EAD post-LDLT is influenced by the recipient's pretransplant health condition and the graft weight. Integrating the model for EAD after LDLT into the pretransplant process of pairing donors and recipients can enhance the safety and efficacy of LDLT., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Liver transplantation (LT) is the main indication for the treatment of end-stage liver disease but have to face organ shortages. Using marginal donors is an option to increase the donor pool. Previous studies showed that the graft procured using N-acetylcysteine (NAC) provides a longer survival compared to perfusion with standard solutions, especially in marginal liver donors. We now evaluate the effect of NAC perfusion compared to control (no NAC protocol) at a 5-year follow-up, with a special focus on the overall survival (OS) and graft survival., Methods: Single-center, retrospective review of the OS and graft survival among NAC and control group, with a sub-stratification based on the LT indication., Results: 140 donors were enrolled: 69 in the NAC protocol and 71 in the control group. The 5-year OS was 84% in the NAC protocol compared to 63% in the control (P = .0045). In LT for HCC, the OS at 5 years was 80% and 55% in the study group and control group, respectively (P = .04), with no statistical difference in the RFS (P = .46). Furthermore, in cost analysis, the resources needed for the NAC protocol is negligible compared to the control group. Beneficial tendency of NAC protocol application has been seen in the other organs (lungs, hearts, pancreas, kidney and intestine) CONCLUSION: The application of NAC infusion in liver donors improves the overall survival of the recipient, especially in the HCC and HCV LT indications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 Elsevier Inc. All rights reserved.)