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

Abstract

Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR Ն 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 Ϯ 43 minutes for A, 96 Ϯ 57 minutes for B, and 453 Ϯ 152 minutes for C, P ϭ 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P ϭ 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P ϭ 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation. Liver Transpl 15: 1776Transpl 15: -1782Transpl 15: , 2009 Adult-to adult right-lobe living donor liver transplantation (RL-LDLT) has gained widespread acceptance during the last 10 years as an alternative to deceased donor liver transplantation. Although living donor (LD) grafts are always from high-quality donors and are less likely to suffer from reperfusion injury, there is ...

Volumetry-based selection of right posterior sector grafts for adult living donor liver transplantation

“…Recent studies have shown that small grafts (GRWR < 0.8%) can be used safely without adverse effects on the long-term graft survival for select patients. 18,19 In this study, the posttransplant laboratory tests showed that the serum bilirubin levels were significantly higher in RPS graft recipients versus RL graft recipients between the third and ninth postoperative days (Fig. 4).…”

Durability of small‐for‐size living donor allografts

“…The results were comparable to larger living donor grafts in our center (GW/SLV >35%; 5-year survival, 78.4%-88.5%). When converted to a median GRWR of 0.59 (range, 0.56-0.64), our smaller grafts had better longterm survival (Moon et al, 24 GRWR, 0.74 6 0.05; 5-year survival, 74.1%; Selzner et al, 25 GRWR, 0.72 6 0.63; 5-year survival, 79%) than larger grafts in other series. Our liver grafts included the middle hepatic vein, whereas from Selzner et al, 25 the 53% of SFS grafts did.…”

“…When converted to a median GRWR of 0.59 (range, 0.56-0.64), our smaller grafts had better longterm survival (Moon et al, 24 GRWR, 0.74 6 0.05; 5-year survival, 74.1%; Selzner et al, 25 GRWR, 0.72 6 0.63; 5-year survival, 79%) than larger grafts in other series. Our liver grafts included the middle hepatic vein, whereas from Selzner et al, 25 the 53% of SFS grafts did. In the series from Moon et al, 24 the middle hepatic vein was not taken but was reconstructed with a vein graft in 63% of their SFS grafts.…”

“…Long-term survival of SFS graft has been discussed in the literature. Moon et al, 24 Selzner et al, 25 and Chen et al 26 reported no inferior outcomes in liver grafts with GRWR < 0.8, which represented a GW/ SLV < 40%. Nevertheless, the long-term outcomes of liver grafts smaller than 35% of ESLV remained scarce in current literature.…”

Living Donor Liver Transplantation

“…Patients with significant decompensation of chronic liver disease will have excessive metabolic demands and require the maximum liver volume available. On the other hand, some authorities ( Selzner et al, 2009) suggest that, patients with Child's class A cirrhosis or those without portal hypertension could receive an allograft with a GRBWR greater than 0.6%. Marcos A (2000) summarized the issue of hepatic mass by stating, "Neither the minimum transplantable hepatic mass nor the optimal mass have been accurately determined.…”