The role of graft to recipient weight ratio on enhanced recovery of the recipient after living donor liver transplantation – A systematic review of the literature and expert panel recommendations

Abstract

Background There continues to be debate about the lower limit of graft‐to‐recipient weight ratio (GRWR) for living donor liver transplant (LDLT). Objectives To identify the lower limit of GRWR compatible with enhanced recovery after living donor liver transplant and to provide international expert panel recommendations. Data sources Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Methods Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies assessing how GRWR affects recipient outcomes such as small for size syndrome, other complications, patient and graft survival, and length of stay were included. Protocol registration: CRD42021260794. Results Twenty articles were included in the qualitative synthesis, and all were retrospective observational studies. There was heterogeneity in the definition of study cohorts and key outcome measures such as small‐for‐size syndrome. Most studies lacked risk adjustment given limited single‐center sample size. GRWR of ≥ .8% is associated with enhanced recovery. Recipients of grafts with GRWR < .8%, however, were found to have similar outcomes as those with ≥ .8% when appropriate consideration is made for portal flow modulation and recipient illness severity. Conclusions GRWR ≥ .8% is often compatible with enhanced recovery, but grafts < .8% can be used in selected LDLT recipients with optimal donor‐recipient selection, surgical technique, and perioperative management (Quality of Evidence; Low | Grade of Recommendation; Strong).

Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference

“…Systematic review and expert panel recommendations from the Enhanced Recovery for Liver Transplant (ERAS4OLT) consensus conference strongly recommended that SFSG with GRWR <0.8 are also compatible with enhanced recovery in selected LDLT recipients with optimal donor-recipient selection, surgical technique involving portal inflow modulation, and precise perioperative management. 52,53…”

“…Systematic review and expert panel recommendations from the Enhanced Recovery for Liver Transplant (ERAS4OLT) consensus conference strongly recommended that SFSG with GRWR <0.8 are also compatible with enhanced recovery in selected LDLT recipients with optimal donor-recipient selection, surgical technique involving portal inflow modulation, and precise perioperative management. 52,53 Additionally, anticoagulant prophylaxis has to be balanced with the risk of bleeding because of coagulopathy, which can be more common with SFSGs. In a study of 314 adult LT recipients, the estimated risk of developing a deep vein thrombosis (DVT) was found to be >9% even with the use of mechanical prophylaxis.…”

Increasing practice and acceptable outcomes of high-MELD living donor liver transplantation in the USA

“…Currently, the nature of this practice (geographic variation, outcomes, optimal donor and recipient selection) remains debatable. [11][12][13] There are conflicting international data if MELD score confers additional mortality risk in LDLT, and a paucity of data from the United States exists, with 1 single-center study reporting no significant difference in postoperative LDLT outcomes based on MELD score. [9,10,14] Understanding the impact of MELD score on post-LDLT outcomes is essential, given that high-MELD LDLT will likely continue increasing in response to ongoing donor allocation changes.…”

An Analysis of 10,000 Cases of Living Donor Liver Transplantation in Japan

“…[11][12][13] Therefore, the graft-versus-recipient weight ratio (GRWR) has been used as a simple calculation method for LDLT. [14][15][16] Previous studies have examined specific factors affecting outcomes using grafts with various GRWRs. [17][18][19] In addition, the appropriate donor age for LDLT with regard to the GRWR or graft type remains controversial.…”

“…The standard liver volume (SLV) can be calculated using many formulas, but the recipient weight at the time of LT is not always suitable for the procedure because of sarcopenia or weight gain in nonalcoholic steatohepatitis patients or due to ascites retention 11–13 . Therefore, the graft-versus-recipient weight ratio (GRWR) has been used as a simple calculation method for LDLT 14–16 . Previous studies have examined specific factors affecting outcomes using grafts with various GRWRs 17–19 .…”