Severe graft dysfunction as opposed to the expected immediate graft function following liver transplantation is a major complication, and the clinical manifestations of such that lead to either immediate re-transplantation or patient death are the catastrophic end of the spectrum. Primary non-function (PNF) has declined in incidence over the years, yet the impact on patient and healthcare teams, and the burden on the organ pool in case of the need for re-transplant should not be underestimated. There is no universal test to define the diagnosis of PNF and current criteria are based on various biochemical parameters surrogate of liver function, and moreover a disparity remains within different healthcare systems on selecting candidates eligible for urgent re-transplantation. The impact on PNF from traditionally accepted risk factors has changed somewhat, mainly driven by the rising demand for organs, combined with the concerted approach by clinicians on the in-depth understanding of PNF, optimal graft recipient selection, mitigation of clinical environment a marginal graft being reperfused and post-operative management. Regardless of the mode, available data suggests machine perfusion strategies perhaps help reduce the incidence further but does not completely avert the risk of PNF. The mainstay of management relies on identifying severe allograft dysfunction at a very early stage and aggressive management whilst excluding other identifiable causes that mimic severe organ dysfunction. This approach may help salvage some grafts by preventing total graft failure, and also maintaining a patient in an optimal physiological state if re-transplantation is considered the ultimate patient salvage strategy.Supplemental Visual Abstract; http://links.lww.com/TP/C143
