Early Graft Dysfunction in Living Donor Liver Transplantation and the Small for Size Syndrome. Curr Transplant Rep. 2014;1:43-52. [PMID: 27280080 DOI: 10.1007/s40472-013-0006-1]

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.

Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.

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

BACKGROUND

During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS).

METHODS

A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India.

RESULTS

It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion.

CONCLUSIONS

Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.

The current status and outcomes of pediatric liver transplantation in western China: A multi-center retrospective study

This retrospective study was conducted to examine the development and current status of pediatric liver transplantation (LT) in western China. Clinical, demographic, morbidity, and mortality data were collected to analyze. It included 260 consecutive pediatric LTs performed at three centers in western China between January 2000 and May 2019. Kaplan-Meier graft survival rates at 1, 3, 5, and 10 years were 82.1%, 77.2%, 76.6%, and 76.6%, respectively; corresponding patient survival rates were 84.7%, 80.7%, 80.0%, and 80.0%, respectively. More patients underwent living donor liver transplantation (LDLT; n = 188 (73.4%)) than deceased-donor liver transplantation (DDLT; n = 68 (26.6%)). Survival was better after LDLT (91.5%, 86.6%, and 80.6% at 1, 3, and 5 years, respectively) than after DDLT (80.9%, 72.4%, and 63.9%, respectively; P < .05). Biliary atresia was the leading LT indication (n = 141 (55.1%)), followed by metabolic disease (n = 36 (14.1%)), which was associated with the best recipient survival (88.5% at 5 years). The transplant era and graft-to-recipient body weight ratio (GRWR) also significantly predicted overall survival. Survival rates at 5 years were worst in 2000-2005 (54.5%) and best for GRWRs of 0.8%-4% (80.4%). The development of pediatric LT in western China began slowly, but the quantity and quality of pediatric LT has progressed in recent years. This procedure is now a promising and reliable treatment for children with end-stage liver disease in western China.

The pathogenesis of portal hypertension differs between small for size syndrome (SFSS) and postoperative liver Failure(POLF)

The pathogenesis of portal hypertension differs in patients with small for size syndrome (SFSS) after living donor liver transplantation (LDLT) and postoperative liver failure (POLF) after liver resection. This difference has important implications in the prevention and management of POLF.

The postoperative hepatic artery resistance index after living donor liver transplantation can predict early allograft dysfunction

To investigate whether postoperative hepatic hemodynamics have an impact on graft function.Using a retrospective cohort with 262 adult living donor liver transplantation (LDLT) recipients, we discussed the relationship between postoperative hepatic hemodynamics and patient outcomes.According to the definition of early allograft dysfunction (EAD), the patients were classified into the EAD group (43 patients) and the non-EAD group (219 patients). In terms of postoperative hemodynamic parameters, there was no significant differences between these 2 groups regarding hepatic artery flow (HAF), hepatic artery velocity (HAV), portal vein flow (PVF), and portal vein velocity (PVV), except for the hepatic artery resistance index (HARI) which was somewhat higher in the EAD group on postoperative day 3 (POD3) (0.70 vs 0.61, P < .05). According to these results, we used a ROC curve and found that a HARI of 0.68 was the cutoff point (with 73.8% sensitivity and 58.3% specificity) for predicting EAD after LDLT. In addition, multivariate analysis showed that fulminant hepatic failure, pretransplant hepatorenal syndrome, and HARI ≥ 0.68 on POD3 were independent risk factors for postoperative EAD.Our results showed that postoperative hemodynamics might influence graft function by altering hepatic artery flow.

Liver Transplantation

The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.

Living Donor Liver Transplantation: Overview, Imaging Technique, and Diagnostic Considerations

OBJECTIVE. The purpose of this article is to discuss the process of becoming a liver donor, describe the surgical methods used for transplantation, and critically review preoperative and intraoperative imaging techniques. CONCLUSION. Radiologists play a vital role in ensuring the safety of living liver donors; however, consensus guidelines do not exist for imaging protocol or reporting. Standardization would provide more consistent image quality across centers, improve communication with the transplant team, and facilitate data mining for quality assurance and research.

Recipient Outcomes with Younger Donors Undergoing Living Donor Liver Transplantation

Introduction

The impact of donor age on liver transplantation is well known. Data on an appropriate donor age cut-off for living donor liver transplantation (LDLT) with a background of hepatitis C (HCV) is generally limited. The objective of this study was to determine whether limiting donor age to less than 35 years improved outcomes in patients with HCV-related end-stage liver disease (ESLD).

Methods

This was a retrospective review of 169 patients who underwent LDLT for HCV-related ESLD. The patients were divided into two groups based on whether they received grafts from donors ≤ 35 (Group 1) or > 35 (Group 2) years of age. Kaplan Meier curves were used to determine survival. Uni and multivariate analysis were performed to determine independent predictors of mortality.

Results

Mean donor age was 25.1 ± 5.2 and 40.1 ± 3.4 years (P < 0.0001). Early allograft dysfunction (EAD) was seen in 11.7% patients in Group 1 versus 29.6% in Group 2 (P = 0.02). A significant difference in mortality was present between the two groups, i.e., 33.3% versus 15.8% (P = 0.04). The estimated four-year overall survival (OS) was 78% and 64% (P = 0.03). Upon doing univariate analysis, the donor age (P = 0.04) and EAD (P = 0.006) were found to be significant variables for mortality. On multivariate analysis, EAD was the only independent predictor of mortality (Hazard ratio: 2.6; confidence interval: 1.1 - 5.8; P = 0.01).

Conclusion

Opting for younger donors (≤ 35 years) for HCV-related ESLD patients lowers the risk of EAD and improves overall survival.

Survival Outcomes in Split Compared With Whole Liver Transplantation

Split-liver transplantation (SLT) should be cautiously considered because the right trisection (RTS) graft can be a marginal graft in adult recipients. Herein, we analyzed the outcomes of RTS-SLT in Korea, where >75% of adult liver transplantations are performed with living donor liver transplantation. Among 2462 patients who underwent deceased donor liver transplantations (DDLTs) from 2005 to 2014, we retrospectively reviewed 86 (3.5%) adult patients who received a RTS graft (RTS-SLT group). The outcomes of the RTS-SLT group were compared with those of 303 recipients of whole liver (WL; WL-DDLT group). Recipient age, laboratory Model for End-Stage-Liver Disease (L-MELD) score, ischemia time, and donor-to-recipient weight ratio (DRWR) were not different between the 2 groups (P > 0.05). However, malignancy was uncommon (4.7% versus 36.3%), and the donor was younger (25.2 versus 42.7 years) in the RST-SLT group than in the WL-DDLT group (P < 0.05). The technical complication rates and the 5-year graft survival rates (89.0% versus 92.8%) were not different between the 2 groups (P > 0.05). The 5-year overall survival (OS) rate (63.1%) and graft-failure-free survival rate (63.1%) of the RTS-SLT group were worse than that of the WL-DDLT group (79.3% and 79.3%; P < 0.05). The factors affecting graft survival rates were not definite. However, the factors affecting OS in the RTS-SLT group were L-MELD score >30 and DRWR ≤1.0. In the subgroup analysis, OS was not different between the 2 groups if the DRWR was >1.0, regardless of the L-MELD score (P > 0.05). In conclusion, a sufficient volume of the graft estimated from DRWR-matching could lead to better outcomes of adult SLTs with a RTS graft, even in patients with high L-MELD scores.

Feasibility of using marginal liver grafts in living donor liver transplantation

Liver transplantation (LT) is one of the most effective treatments for end-stage liver disease caused by related risk factors when liver resection is contraindicated. Additionally, despite the decrease in the prevalence of hepatitis B virus (HBV) over the past two decades, the absolute number of HBsAg-positive people has increased, leading to an increase in HBV-related liver cirrhosis and hepatocellular carcinoma. Consequently, a large demand exists for LT. While the wait time for patients on the donor list is, to some degree, shorter due to the development of living donor liver transplantation (LDLT), there is still a shortage of liver grafts. Furthermore, recipients often suffer from emergent conditions, such as liver dysfunction or even hepatic encephalopathy, which can lead to a limited choice in grafts. To expand the pool of available liver grafts, one option is the use of organs that were previously considered “unusable” by many, which are often labeled “marginal” organs. Many previous studies have reported on the possibilities of using marginal grafts in orthotopic LT; however, there is still a lack of discussion on this topic, especially regarding the feasibility of using marginal grafts in LDLT. Therefore, the present review aimed to summarize the feasibility of using marginal liver grafts for LDLT and discuss the possibility of expanding the application of these grafts.

Living Donor Liver Transplantation: Technical Innovations

Living donor liver transplantation (LDLT) has found a place to serve the end-stage liver disease community as the donor safety and recipient suitability has been elucidated. Donor safety is of paramount importance and transplant programs must continue endeavors to maintain the highest possible standards. At the same time, adequacy of grafts based on recipient clinical status via their model for end-stage liver disease (MELD) score and volumetric studies to achieve a GRBWR >0.8, along with special attention to anatomic tailoring and portal venous flow optimization are necessary for successful transplantation. Technical innovations have improved sequentially the utility and availability of LDLT.

Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

AIM

To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome (SFSS) after living donor liver transplantation (LDLT).

METHODS

Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT (A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range (0-144 m).

RESULTS

SFSS was diagnosed in 20 (11.5%) of our recipients. While extra-small graft [small for size graft (SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis (P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis (P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10 (40%) SFSS vs 3/7 (42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe (RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10 (28.6%) SFSS vs 52/152 (34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference (P = 0.00).

CONCLUSION

SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention (i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

AIM

To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome (SFSS) after living donor liver transplantation (LDLT).

METHODS

Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT (A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range (0-144 m).

RESULTS

SFSS was diagnosed in 20 (11.5%) of our recipients. While extra-small graft [small for size graft (SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis (P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis (P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10 (40%) SFSS vs 3/7 (42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe (RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10 (28.6%) SFSS vs 52/152 (34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference (P = 0.00).

CONCLUSION

SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention (i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

Failure to rescue in living donor liver transplantation: Patterns and predictors

BACKGROUND

As a quality assessment tool, failure to rescue (FTR) has been employed in various surgical specialties. However, its role in liver transplantation has only recently been explored. To the best of our knowledge, role of FTR in living donor liver transplant (LDLT) has not been assessed previously. The objective of the current study was to determine failure to rescue (FTR) rate and it's predictors in an LDLT center.

MATERIALS AND METHODS

We reviewed a prospectively maintained database of patients who underwent LDLT at our center between 2012 and 2016. Patients who experienced grade 3B or above complications on Clavien-Dindo grading were included in this study. Primary outcome of interest was FTR rate in these patients. FTR was defined as a preventable major complication followed by death within one year after transplantation. We also looked at independent predictors of FTR in our patients and a multivariate analysis was performed.

RESULTS

Median age was 48.4(18-73) years. Male to female ratio was 3.3:1. Median MELD score was 17(6-42). The FTR rate in the current study was 52/131 (39.6%). Infectious complications were more common in the FTR group i.e. 22/32(68.8%) versus 10/32 (31.2%) (P < 0.0001). Biliary complications were more common in the non-FTR group i.e. 49/62 (79.1%) versus 13/62 (20.9%) (P < 0.0001). On multivariate analysis, there was a 60% increase in mortality following a major complication in the presence of early allograft dysfunction (Hazard ratio: 1.6, Confidence interval; 1.2-2.2, P = 0.002). A 40% reduction in FTR was seen in patients with a biliary complication versus other complications (Hazard ratio: 0.6, Confidence interval = 0.4-0.8, P = 0.009).

CONCLUSION

Early allograft dysfunction and biliary complications are independent predictors of FTR in LDLT.