Strategies and outcome in small for size grafts in living donor liver transplantation

Abstract

Introduction: Graft recipient weight ratio (GRWR) of ≥0.8 is considered gold standard to avoid small for size syndrome (SFSS) in living donor liver transplantation (LDLT). However, lower GRWR (<0.8) have been shown to give equally good outcomes with portal inflow modulation (IM). Aim: To evaluate outcomes of LDLT with small for size grafts. Methods: Among 1264 adult LDLT from 2012 to September 2017, 274 were with GRWR <0.8. Portal pressure (PP) was measured in the dissection, post-reperfusion phases.IM was performed in 121 (44.1%) patients according to GRWR-based protocol Result: Mean age was 49.30 year. The median CTP and MELD scores were 10 (IQR: 8–11) and 14 (IQR: 10–18) respectively. The lowest GRWR was 0.55. 53 recipients had GRWR between 0.55–0.69 (HPCS-52 and HPCS+SAL-1) and 221 had GRWR between 0.70-0.79 (HPCS 54, SAL = 12, Coronary caval shunt-1, HPCS+SAL-1) and 990 had ≥0.80. The median PP in dissection phase and post reperfusion were 27 (IQR: 22-30) and 15 (IQR: 13-22) mm Hg respectively. 12 (4.37%) developed SFSS and six of them died due to SFSS. One year survival of patients across different GRWR were comparable (83.01% vs 82.8% vs 87.7%). Two patients needed partial shunt closure at 1 and 4 weeks; the latter died of sepsis. No other shunt related complications were encountered. Conclusion: The decision of inflow modulation based on GRWR and PP result in acceptable recipient outcomes in small for size grafts and overall patient survival is comparable to grafts with GRWR ≥0.8.