This randomized controlled trial compared normothermic machine perfusion (NMP) with conventional static cold storage (SCS) in 220 liver transplantations. NMP, which maintains the liver at physiological temperature and avoids cooling, was found to be associated with a 50% lower level of graft injury, measured by hepatocellular enzyme release, despite a 50% lower rate of organ discard and a 54% longer mean preservation time. There was no significant difference in bile duct complications, graft survival, or patient survival between the two groups. The results suggest that NMP could improve liver transplant outcomes and reduce waiting list mortality if translated into clinical practice. The study also highlights the potential of NMP to increase organ utilization, particularly from high-risk donors, and to address logistical barriers currently limiting liver transplants.This randomized controlled trial compared normothermic machine perfusion (NMP) with conventional static cold storage (SCS) in 220 liver transplantations. NMP, which maintains the liver at physiological temperature and avoids cooling, was found to be associated with a 50% lower level of graft injury, measured by hepatocellular enzyme release, despite a 50% lower rate of organ discard and a 54% longer mean preservation time. There was no significant difference in bile duct complications, graft survival, or patient survival between the two groups. The results suggest that NMP could improve liver transplant outcomes and reduce waiting list mortality if translated into clinical practice. The study also highlights the potential of NMP to increase organ utilization, particularly from high-risk donors, and to address logistical barriers currently limiting liver transplants.