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

Abstract

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.

Impact of imbalanced graft-to-spleen volume ratio on outcomes following living donor liver transplantation in an era when simultaneous splenectomy is not typically indicated

“…While meticulous strategies and surgical performance have recently enabled satisfactory LDLT outcomes with a graft-to-recipient weight ratio (GRWR) as low as 0.6%, 28 our results suggest that GSVR is a better predictor of graft survival than the GRWR for selected recipients, especially when SPX is not scheduled. 33 While PVP modulation is well known, 10,16 our results indicate that low GSVR may be another indication for SPX in terms of curing hypersplenism. SPX has been performed to correct the effects of low blood cell and platelet counts in severe cases of splenomegaly and hypersplenism.…”

“…Transfused fresh-frozen plasma, U 10 (6-16) 12 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) 12 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) .853…”

“…16 Therefore, comparison excluding PVP-modulated cases may provide information closer to the true effect of SPX in recipients with normal PVP, namely, in recipients in whom it was not necessary or planned. Patients presenting with PHT after reperfusion and requiring SPX for modulation (n = 37) were excluded from the analysis, because SPX is performed to prevent small-for-size syndrome or EGL, and it might have improved the survival curve of those who had spleen preservation with low GSVR by shifting these high-risk patients to the SPX group.…”

“…even a GSVR > 0.70 g/mL; and (2) patients with a GSVR ≤ 0.70 g/mL regardless of PVP. However, considering that the indications for SPX vary according to the institutions in clinical settings,4,7,16,38 the results represent real-world experience. The high risk patients here indicate the recipients who receive grafts from either ABO-incompatible donors or donors age ≥45 years 16.…”

“…The high risk patients here indicate the recipients who receive grafts from either ABO-incompatible donors or donors age ≥45 years 16. In institutions where simultaneous SPX has been abandoned, other alternative interventions such as splenic artery ligation/embolization or platelet transfusion should be applied.…”