Impact of Small-for-Size Graft on Graft Surgical and Postoperative Complications in Adult Living Donor Liver Transplantation
The adequacy of the size of the liver is the major limitation and most critical issue associated with adult living donor liver transplantation (LDLT). The impact of graft size on the outcome of the transplantion patient is clearly demonstrated in our 1-year survival results in non-intensive care unit (ICU)-bound patients. The 1-year survival rate was 91.8% in those with a graft/recipient weight ratio (GRWR) of ≥1.0%, 79.5% among those with a GRWR of 0.8%–1.0%, and 59.7% among those with a GRWR of <0.8%. The difference by graft size was even greater in ICU-bound patients. The decreased survival in small-for-size grafts was accompanied by poor early graft function and hepatocyte injury as well as by prolonged cholestasis. Moreover, the incidence of surgical complications (e.g., hemorrhage, intestinal perforation) and septic complications were in inverse correlation with graft size relative to the recipient. The posttransplant serum creatinine level is inversely correlated with graft size; and the incidence of bacteremia within 1 month after transplantation increased as the GRWR decreased. With technical refinements backed by precise knowledge of anatomical variations and physiology, we believe right lobe LDLT has become a highly effective treatment modality, with acceptable risk for both donors and recipients. In countries where cadaveric organ donation is not well organized, this procedure will remain, at least for a while, in the mainstream of liver transplantation.