Older Donor Age Is a Risk Factor for Negative Outcomes After Adult Living Donor Liver Transplantation Using Small-for-Size Grafts.

Adult-to-adult living donor liver transplantation (ALDLT) using small-for-size grafts (SFSGs), ie, a graft with a graft-to-recipient weight ratio (GRWR) <0.8%, has been a challenge that should be carefully dealt with, and risk factors in this category are unclear. Therefore, we aimed to examine the risk factors and outcomes of ALDLT using SFSGs over a 13-year period in 121 patients who had undergone their first ALDLT using SFSGs. Small-for-size syndrome (SFSS), early graft loss, and 1-year mortality were encountered in 21.6%, 14.9%, and 18.4% of patients, respectively. By multivariate analysis, older donor age (≥45 years) was an independent risk factor for SFSS (odds ratio [OR], 4.46; P = 0.004), early graft loss (OR, 4.11; P = 0.02), and 1-year mortality (OR, 3.76; P = 0.02). Child-Pugh C class recipients were associated with a higher risk of SFSS development (P = 0.013; OR, 7.44). Despite no significant difference between GRWR categories in the multivariate outcome analysis of the whole population, in the survival analysis of the 2 donor age groups, GRWR <0.6% was associated with significantly lower 1-year survival than the other GRWR categories in the younger donor group. Moreover, in the high final portal venous pressure (PVP) group (>15 mm Hg), younger ABO-compatible donors showed 100% 1-year survival with a significant difference from the group of other donors. Older donor age was an independent risk factor for SFSS, early graft loss, and 1-year mortality after ALDLT using SFSGs. GRWR should not be <0.6%, and PVP modulation is indicated when grafts from older or ABO-incompatible donors are used.

Macshut M ，Kaido T ，Yao S ，Yagi S ，Ito T ，Kamo N ，Nagai K ，Sharshar M ，Uemoto S ... -  《-》

Is Portal Venous Pressure Modulation Still Indicated for All Recipients in Living Donor Liver Transplantation?

There is a consensus that portal venous pressure (PVP) modulation prevents portal hypertension (PHT) and consequent complications after adult-to-adult living donor liver transplantation (ALDLT). However, PVP-modulation strategies need to be updated based on the most recent findings. We examined our 10-year experience of PVP modulation and reevaluated whether it was necessary for all recipients or for selected recipients in ALDLT. In this retrospective study, 319 patients who underwent ALDLT from 2007 to 2016 were divided into 3 groups according to the necessity and results of PVP modulation: not indicated (n = 189), indicated and succeeded (n = 92), and indicated but failed (n = 38). Graft survival and associations with various clinical factors were investigated. PVP modulation was performed mainly by splenectomy to lower final PVP to ≤15 mm Hg. Successful PVP modulation improved prognosis to be equivalent to that of patients who did not need modulation, whereas failed modulation was associated with increased incidence of small-for-size syndrome (SFSS; P = 0.003) and early graft loss (EGL; P = 0.006). Among patients with failed modulation, donor age ≥ 45 years (hazard ratio [HR], 3.67; P = 0.02) and ABO incompatibility (HR, 3.90; P = 0.01) were independent risk factors for graft loss. Survival analysis showed that PVP > 15 mm Hg was related to poor prognosis in grafts from either ABO-incompatible or older donor age ≥ 45 years (P < 0.001), but it did not negatively affect grafts from ABO-compatible/identical and young donor age < 45 years (P = 0.27). In conclusion, intentional PVP modulation is not necessarily required in all recipients. Although grafts from both ABO-compatible/identical and young donors can tolerate PHT, lowering PVP to ≤15 mm Hg is a key to preventing SFSS and consequent EGL with grafts from either ABO-incompatible or older donors.

Yao S ，Kaido T ，Uozumi R ，Yagi S ，Miyachi Y ，Fukumitsu K ，Anazawa T ，Kamo N ，Taura K ，Okajima H ，Uemoto S ... -  《-》

Is Portal Inflow Modulation Always Necessary for Successful Utilization of Small Volume Living Donor Liver Grafts?

Although the well-accepted lower limit of the graft-to-recipient weight ratio (GRWR) for successful living donor liver transplantation (LDLT) remains 0.80%, many believe grafts with lower GRWR may suffice with portal inflow modulation (PIM), resulting in equally good recipient outcomes. This study was done to evaluate the outcomes of LDLT with small-for-size grafts (GRWR <0.80%). Of 1321 consecutive adult LDLTs from January 2012 to December 2017, 287 (21.7%) had GRWR <0.80%. PIM was performed (hemiportocaval shunt [HPCS], n = 109; splenic artery ligation [SAL], n = 14) in 42.9% patients. No PIM was done if portal pressure (PP) in the dissection phase was <16 mm Hg. Mean age of the cohort was 49.3 ± 9.1 years. Median Model for End-Stage Liver Disease score was 14, and the lowest GRWR was 0.54%. A total of 72 recipients had a GRWR <0.70%, of whom 58 underwent HPCS (1 of whom underwent HPCS + SAL) and 14 underwent no PIM, whereas 215 had GRWR between 0.70% and 0.79%, of whom 51 and 14 underwent HPCS and SAL, respectively. During the same period, 1034 had GRWR ≥0.80% and did not undergo PIM. Small-for-size syndrome developed in 2.8% patients. Three patients needed shunt closure at 1 and 4 weeks and 60 months. The 1-year patient survival rates were comparable. In conclusion, with PIM protocol that optimizes postperfusion PP, low-GRWR grafts can be used for appropriately selected LDLT recipients with acceptable outcomes.

Soin AS ，Yadav SK ，Saha SK ，Rastogi A ，Bhangui P ，Srinivasan T ，Saraf N ，Choudhary NS ，Saigal S ，Vohra V ... -  《-》

Living donor liver transplantation in patients weighing ≥100 kg: Low graft weight and obesity do not impact outcomes.

Living donor liver transplantation (LDLT) in obese patients raises concerns with regards to obtaining grafts of "adequate" graft-to-recipient weight ratio (GRWR) and the impact of obesity on the outcomes of LDLT. LDLT outcomes in patients weighing ≥100 kg were compared with those weighing <100 kg. Patients weighing ≥100 kg were divided into 3 categories based on the GRWR of the grafts they received. Groups 1, 2, and 3 included patients with GRWR ≥0.8%, between 0.65% and 0.8%, and <0.65%, respectively. The 56 (6.5%) adult liver transplants were performed in patients weighing 100 kg or more. Except for higher mean body mass index (35.8 versus 25.2 kg/m2 ; P value < 0.01) and grafts of lower GRWR in obese patients (0.74% versus 1.02%; P value < 0.01), all other parameters were similar between the 2 groups. Despite obesity and smaller grafts, the posttransplant outcomes such as day to normal bilirubin and international normalized ratio; infective, respiratory, and biliary complications; and hospital mortality were similar between the 2 groups. On comparing obese patients in the 3 GRWR categories, except for graft weight (985 versus 769 versus 646 g; P value < 0.01), all the pretransplant parameters were comparable. There was no significant difference in terms of graft function, postoperative morbidity, and hospital mortality between patients with grafts of normal GRWR and those with grafts of low and very low GRWR. Grafts of low GRWR give satisfactory results in obese patients undergoing LDLT and obesity does not adversely impact the outcome of LDLT. Liver Transplantation 23:35-42 2017 AASLD.

Agarwal S ，Goyal N ，Nayeem M ，Pareek S ，Gupta S ... -  《-》

Left lobe living donor liver transplantation in adults: What is the safety limit?

Small-for-size syndrome (SFSS) is the most significant cause of graft loss after living donor liver transplantation (LDLT), especially after left lobe (LL) LDLT in adults. The safety limit of applying LL-LDLT in adults without severe SFSS with a high rate of lethality needs to be determined. A total of 207 LL-LDLTs in adults since September 2005 were evaluated to analyze the risk factors for severe SFSS, defined as a serum total bilirubin concentration of ≥20.0 mg/dL after LDLT. Although there were no significant differences in cumulative graft survival after LDLT between medium grafts (graft volume [GV] to standard liver volume [SLV] ratio ≥ 40.0%), small grafts (35.0% ≤ GV/SLV < 40.0%), and extra small grafts (GV/SLV < 35.0%), patients with severe SFSS showed a significantly lower 5-year graft survival rate than those without (42.9% versus 94.3%, respectively; P < 0.001). Multivariate analysis for severe SFSS after LL-LDLT showed that donor age of ≥48 years (P = 0.01), Model for End-Stage Liver Disease (MELD) score of ≥ 19 (P < 0.01), and end portal venous pressure of ≥19 mm Hg (P = 0.04) were the significant and independent factors for severe SFSS after LL-LDLT. Within such high-risk subgroups of patients with a donor age of ≥48 years or MELD score of ≥ 19 before LDLT, operative blood loss volume of ≥8.0 L was a risk factor for severe SFSS. LL-LDLT in adults could be indicated and provide acceptable outcomes for the combinations of donors aged < 48 years and recipients with a MELD score of <19. Smaller grafts might yield acceptable outcomes in appropriately selected donor-recipient combinations. Liver Transplantation 22 1666-1675 2016 AASLD.

Ikegami T ，Yoshizumi T ，Sakata K ，Uchiyama H ，Harimoto N ，Harada N ，Itoh S ，Nagatsu A ，Soejima Y ，Maehara Y ... -  《-》