Korean J Transplant.  2019 Dec;33(4):65-73. 10.4285/jkstn.2019.33.4.65.

Conceptual changes in small-for-size graft and small-for-size syndrome in living donor liver transplantation

Affiliations
  • 1Department of Surgery and Science, Kyushu University, Fukuoka, Japan. tikesurg@surg2.med.kyushu-u.ac.jp
  • 2Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
  • 3Department of Liver Transplantation and Hepatobiliary and Pancreatic Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea.
  • 4Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
  • 5Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Korea.

Abstract

Early series in living donor liver transplantation (LDLT) in adults demonstrated a lower safe limit of graft volume standard liver volume ratio 25%-45%. A subsequent worldwide large LDLT series proposed a 0.8 graft recipient weight ratio (GRWR) to define small-for-size graft (SFSG) in adult LDLT. Thereafter, researchers identified innate and inevitable factors including changes in liver volume during imaging studies and graft shrinkage due to perfusion solution. Although the definition of small-for-size syndrome (SFSS) advocated in the 2000s was mainly based on prolonged cholestasis and ascites output, the term SFSS was inadequate to describe clinical manifestations possibly caused by multiple factors. Thus, the term "early allograft dysfunction (EAD)," characterized by total bilirubin >10 mg/dL or coagulopathy with international normalized ratio >1.6 on day 7, has become prevalent to describe graft dysfunction including SFSS after LDLT. Although various efforts have been made to overcome EAD in LDLT, graft selection to maintain an expected GRWR >0.8 and full venous drainage, as well as inflow modulation using splenic artery ligation, have become standard in recent LDLT.

Keyword

Living donor liver transplantation; Small-for-size graft; Small-for-size-syndrome; Early allograft dysfunction

MeSH Terms

Adult
Allografts
Ascites
Bilirubin
Cholestasis
Drainage
Humans
International Normalized Ratio
Ligation
Liver Transplantation*
Liver*
Living Donors*
Perfusion
Splenic Artery
Transplants*
Bilirubin

Figure

  • Fig. 1 Severe hepatocyte ballooning with cholestasis around the pericentral venous area (A) and the recovering phase (B), representing early allograft dysfunction (EAD) including small-for-size syndrome. The pathological findings with EAD can be distinguished from those of cholestatic lobular hepatitis C with panlobular hepatocyte ballooning (C) and acute rejection with mixed cellular infiltrations around the periportal area (D). Black arrows indicate central veins.


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