Graft weight/recipient weight ratio: how well does it predict outcome after partial liver transplants?

Partial graft liver recipients with graft weight/recipient weight (GW/RW) ratios < 0.8% are thought to have a higher incidence of postoperative complications, including small-for-size syndrome (SFSS). We analyzed a cohort of such recipients and compared those with GW/RW < 0.8% to those with GW/RW >or= 0.8%. Between 1999 and 2008, 107 adult patients underwent partial graft liver transplants: 76 from live donors [living donor liver transplantation (LDLT)] and 31 from deceased donors [split liver transplantation (SLT)]. Of these, 22 had GW/RW < 0.8% (12 with LDLT and 10 with SLT), and 85 had GW/RW >or= 0.8% (64 with LDLT and 21 with SLT). The baseline demographics and median length of follow-up were similar. SFSS developed in 3 recipients with GW/RW < 0.8% (13.6%) and in 8 recipients with GW/RW >or= 0.8% (9.4%; P = not significant). Other early complications were similar between the 2 groups. Inflow modification with splenic artery occlusion was performed in 13 recipients: 7 with GW/RW < 0.8% and 6 with GW/RW >or= 0.8%. Graft survival at 1 year post-transplant did not differ (91% versus 92%; P = not significant). In conclusion, GW/RW did not appear to be the only determinant of outcome after partial liver transplantation. Using techniques such as inflow modification may help to prevent some of the problems seen with smaller grafts.

Hill MJ ，Hughes M ，Jie T ，Cohen M ，Lake J ，Payne WD ，Humar A ... -  《-》

Left lobe adult-to-adult living donor liver transplantation: small grafts and hemiportocaval shunts in the prevention of small-for-size syndrome.

Adult-to-adult living donor liver transplantation (AA-LDLT) has better outcomes when a graft weight to recipient weight ratio (GW/RW) > 0.8 is selected. A smaller GW/RW may result in small-for-size syndrome (SFSS). Portal inflow modulation seems to effectively prevent SFSS. Donor right hepatectomy is associated with greater morbidity and mortality than left hepatectomy. In an attempt to shift the risk away from the donor, we postulated that left lobe grafts with a GW/RW < 0.8 could be safely used with the construction of a hemiportocaval shunt (HPCS). We combined data from 2 centers and selected suitable left lobe living donor/recipient pairs. Since January 2005, 21 patients underwent AA-LDLT with left lobe grafts. Sixteen patients underwent the creation of an HPCS between the right portal vein and the inferior vena cava. The portocaval gradient (portal pressure - central venous pressure) was measured before the unclamping of the shunt and 10 minutes after unclamping. The median actual graft weight was 413 g (range = 350-670 g), and the median GW/RW was 0.67 (range = 0.5-1.0). The portocaval gradient was reduced from a median of 18 to 5 mmHg. Patient survival and graft survival at 1 year were 87% and 81%, respectively. SFSS developed in 1 patient, who required retransplantation. Two patients died at 3 and 10 months from a bile leak and fungal sepsis, respectively. The median recipient bilirubin level and INR were 1.7 mg/dL and 1.1, respectively, at 4 weeks post-transplant. One donor had a bile leak (cut surface). This is the first US series of small left lobe AA-LDLT demonstrating that the transplantation of small grafts with modulation of the portal inflow by the creation of an HPCS may prevent the development of SFSS while at the same time providing adequate liver volume. As it matures, this technique has the potential for widespread application and could positively effect donor safety, the donor pool, and waiting list times.

Botha JF ，Langnas AN ，Campos BD ，Grant WJ ，Freise CE ，Ascher NL ，Mercer DF ，Roberts JP ... -  《-》

A graft to body weight ratio less than 0.8 does not exclude adult-to-adult right-lobe living donor liver transplantation.

Selzner M ，Kashfi A ，Cattral MS ，Selzner N ，Greig PD ，Lilly L ，McGilvray ID ，Therapondos G ，Adcock LE ，Ghanekar A ，Levy GA ，Renner EL ，Grant DR ... -  《-》

Delayed splenic artery occlusion for treatment of established small-for-size syndrome after partial liver transplantation.

We looked at the impact of delayed splenic artery occlusion (SAO) on recipients with established small-for-size syndrome (SFSS) after partial graft liver transplantation [either from a living donor (LD) or split from a deceased donor (DD)]. Between 1999 and 2007 we performed a total of 100 partial liver transplantations in adult recipients: 66 LD transplantations and 34 DD split transplantations. Of these, 7 (7%) developed SFSS, diagnosed by the clinical features of cholestasis, coagulopathy, and ascites. Mean graft weight/recipient weight (GW/RW) ratio in these 7 recipients was 0.94%. Five of these 7 recipients underwent relaparotomy at a mean of 10 days post-transplantation to rule out a technical complication, and then intraoperative splenic artery ligation was performed. The other 2 recipients were treated radiologically by splenic artery coiling-at 9 and 13 days post-transplantation. Median serum bilirubin at the time of the splenic artery procedure was 20 mg/dL; by 3 weeks postprocedure this had decreased to 2.5 mg/dL. Of the 7 recipients with SFSS, 6 improved and eventually obtained normal graft function; 1 recipient did not improve and ultimately underwent retransplantation because of persistent cholestasis and failure to thrive. Delayed SAO represents a potential option for the treatment of recipients with established SFSS after partial liver transplantation.

Humar A ，Beissel J ，Crotteau S ，Cohen M ，Lake J ，Payne WD ... -  《-》

Improved outcome of adult recipients with a high model for end-stage liver disease score and a small-for-size graft.

Yi NJ ，Suh KS ，Lee HW ，Shin WY ，Kim J ，Kim W ，Kim YJ ，Yoon JH ，Lee HS ，Lee KU ... -  《-》