How far can we lower graft-to-recipient weight ratio for living donor liver transplantation under modulation of portal venous pressure?

Uemura, Tadahiro; Wada, Seidai; Kaido, Toshimi; Mori, Akira; Ogura, Yasuhiro; Yagi, Shintaro; Fujimoto, Yasuhiro; Ogawa, Kohei; Hata, Koichiro; Yoshizawa, Atsushi; Okajima, Hideaki; Üemoto, Shinji

doi:10.1016/j.surg.2016.01.009

Cited by 75 publications

(87 citation statements)

References 24 publications

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“…ICG kinetics reflects the functional hepatocyte volume and effective PVF [31,[49][50][51][52] . Advanced selection criteria of a graft with an GRWR of ≥ 0.6 and establishment of a target PVP of ≤ 15 mmHg during LDLT are currently documented for successful LDLT [123][124][125][126] . This defiant set-up with lower GRWR has advantages for donor pool and safety, although these grafts may cause critical problems [40] .…”

Section: Discussionmentioning

confidence: 99%

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

Hori

Ogura

Onishi

et al. 2016

WJH

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Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination Hori T et al . Peculiar hemodynamics in advanced cirrhosis constant (k ICG) in the well-preserved allograft. The k ICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.

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Section: Discussionmentioning

confidence: 99%

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

Hori

Ogura

Onishi

et al. 2016

WJH

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“…Since 2006, PVP measurement and modulation have been applied alongside a gradual decrease in the GRWR in our department. In 2010, we reported that maintaining PVP <15 mm Hg was a key for successful ALDLT using smaller grafts, and therefore, the lower limit of the GRWR could be safely reduced to 0.6% in combination with PVP control . Lately, we have reported that high PVP (>15 mm Hg) did not negatively affect the outcome of recipients with grafts from younger (<45 years old) ABO‐compatible donors .…”

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Older Donor Age Is a Risk Factor for Negative Outcomes After Adult Living Donor Liver Transplantation Using Small‐for‐Size Grafts

et al. 2019

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Adult‐to‐adult living donor liver transplantation (ALDLT) using small‐for‐size grafts (SFSGs), ie, a graft with a graft‐to‐recipient weight ratio (GRWR) <0.8%, has been a challenge that should be carefully dealt with, and risk factors in this category are unclear. Therefore, we aimed to examine the risk factors and outcomes of ALDLT using SFSGs over a 13‐year period in 121 patients who had undergone their first ALDLT using SFSGs. Small‐for‐size syndrome (SFSS), early graft loss, and 1‐year mortality were encountered in 21.6%, 14.9%, and 18.4% of patients, respectively. By multivariate analysis, older donor age (≥45 years) was an independent risk factor for SFSS (odds ratio [OR], 4.46; P = 0.004), early graft loss (OR, 4.11; P = 0.02), and 1‐year mortality (OR, 3.76; P = 0.02). Child‐Pugh C class recipients were associated with a higher risk of SFSS development (P = 0.013; OR, 7.44). Despite no significant difference between GRWR categories in the multivariate outcome analysis of the whole population, in the survival analysis of the 2 donor age groups, GRWR <0.6% was associated with significantly lower 1‐year survival than the other GRWR categories in the younger donor group. Moreover, in the high final portal venous pressure (PVP) group (>15 mm Hg), younger ABO‐compatible donors showed 100% 1‐year survival with a significant difference from the group of other donors. Older donor age was an independent risk factor for SFSS, early graft loss, and 1‐year mortality after ALDLT using SFSGs. GRWR should not be <0.6%, and PVP modulation is indicated when grafts from older or ABO‐incompatible donors are used.

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“…In 2010, we reported that modulation of PVP to <15 mm Hg enabled safe transplantation . Satisfactory ALDLT outcomes with a graft‐to‐recipient weight ratio (GRWR) as low as 0.6% have recently been achieved with PVP modulation …”

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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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How far can we lower graft-to-recipient weight ratio for living donor liver transplantation under modulation of portal venous pressure?

Cited by 75 publications

References 24 publications

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

Older Donor Age Is a Risk Factor for Negative Outcomes After Adult Living Donor Liver Transplantation Using Small‐for‐Size Grafts

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

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