A Novel Predictor of Posttransplant Portal Hypertension in Adult-To-Adult Living Donor Liver Transplantation

Gyoten, Kazuyuki; Mizuno, Shugo; Kato, Hiroyuki; Murata, Yasuhiro; Tanemura, Akihiro; Azumi, Yoshinori; Kuriyama, Naohisa; Kishiwada, Masashi; Usui, Masanobu; Sakurai, Hiroyuki; Isaji, Shuji

doi:10.1097/tp.0000000000001370

Cited by 25 publications

(25 citation statements)

References 29 publications

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“…However, splenectomy may be less predictable, and it fails to be effective in 10%‐26% of patients . This is due to the fact that their effectiveness depends on splenic size, with those with larger spleens and a higher spleen‐to‐liver ratio more likely to benefit . Furthermore, splenectomy is associated with longer operative time, higher risk of venous thrombosis, higher risk of infection, and higher volume of blood loss .…”

Section: Discussionmentioning

confidence: 99%

“…(5,(33)(34)(35)(36)(37)(38)(39) This is due to the fact that their effectiveness depends on splenic size, (40) with those with larger spleens and a higher spleen-to-liver ratio more likely to benefit. (41) Furthermore, splenectomy is associated with longer operative time, higher risk of venous thrombosis, higher risk of infection, and higher volume of blood loss. (42) The blood loss in our series was less than that reported in studies where PIM with splenectomy was done.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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“…Posttransplant portal hypertension (PHT) causes critical problems with liver function and graft regeneration after liver transplantation; intraoperative portal venous pressure (PVP) modulation has been performed to reduce PHT. (1)(2)(3)(4)(5)(6) With accumulated evidence, consensus has been reached on the use of PVP modulation to improve graft function and prevent small-for-size syndrome (SFSS). PVP modulation was initially achieved with portocaval shunting; splenectomy is currently the most common procedure for PVP modulation.…”

Section: See Editorial On Page 1506mentioning

confidence: 99%

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

Yao¹,

Kaido²,

Uozumi

et al. 2018

Liver Transpl

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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.

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“…The intrahepatic vascular resistance is related to the size and quality of the graft. The hemodynamic status is related to the spleen volume and the development of collateral vessels [8,19]. Although the GV/SLV and GRWR are generally accepted as important predictors of the adequacy of the post-transplant liver function (GV/SLV ≥ 35%, GRWR ≥ 0.08%) [4,6], we have encountered some patients whose post-transplant course was not good despite meeting these criteria.…”

Section: Discussionmentioning

confidence: 97%

“…Furthermore, Gyoten et al . revealed that a spleen volume‐to‐graft volume ratio > 0.95 was a good predictor of a high PVP (>20 mmHg) after reperfusion in ALDLT, regardless of the MELD score, Child‐Pugh score, or graft type . However, there are no reports on the relationship between the GV/SV and PVF for recipients, including children.…”

Section: Discussionmentioning

confidence: 99%

Liver graft-to-spleen volume ratio as a useful predictive factor of the early graft function in children and young adults transplanted for biliary atresia: a retrospective study

et al. 2018

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A graft volume/standard liver volume ratio (GV/SLV) > 35% or graft/recipient weight ratio (GRWR) > 0.8% has been considered as a standard criteria of graft selection. Even if the graft size meets these selection criteria, small-for-size syndrome can still occur depending on the portal venous flow (PVF). The aim of this study was to identify other factors contributing to portal hyperperfusion and the post-transplant course, focusing on the graft volume-to-spleen volume ratio (GV/SV). Thirty-seven BA patients who underwent living donor liver transplantation were reviewed retrospectively. First, we evaluated the preoperative factors contributing to portal hyperperfusion. Second, we evaluated the factors contributing to post-transplant complications, such as thrombocytopenia, hyperbilirubinemia, and coagulopathy. The GV/SLV was >35% in all cases; however, portal hyperperfusion (≥250 ml/min/100 g graft) was found in 12 recipients (35.3%). Furthermore, although the GRWR was >0.8% in over 90% of cases, portal hyperperfusion was found in 10 recipients (32.3%). In contrast, the GV/SV showed a significant correlation with the PVF after reperfusion. If the GV/SV was <0.88, about 80% of recipients developed portal hyperperfusion. Furthermore, the GV/SV also showed a significant correlation with post-transplant persistent thrombocytopenia and hyperbilirubinemia. The GV/SV < 0.88 predicts portal hyperperfusion, post-transplant persistent thrombocytopenia, and hyperbilirubinemia.

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A Novel Predictor of Posttransplant Portal Hypertension in Adult-To-Adult Living Donor Liver Transplantation

Cited by 25 publications

References 29 publications

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

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

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

Liver graft-to-spleen volume ratio as a useful predictive factor of the early graft function in children and young adults transplanted for biliary atresia: a retrospective study

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