Prognosis of Split Liver Transplantation Compared with Whole Liver Transplantation in Adult Patients: Single-center Results Under the Korean MELD Score-based Allocation Policy

Abstract

Background Split liver transplantation (SLT) has been occasionally performed in Korea. This study compared the incidence and prognosis of SLT with whole liver transplantation (WLT) in adult patients. Methods Between June 2016 and November 2019, 242 adult patients underwent a total of 256 deceased donor liver transplantation operations. SLT was performed in 7 patients (2.9%). Results The mean age of SLT donors was 29.7 ± 7.4 years, and the mean age of recipients was 55.7 ± 10.6 years, with the latter having a mean model for end-stage liver disease score of 34.6 ± 3.1. Mean split right liver graft weight was 1,228.6 ± 149.7 g and mean graft-recipient weight ratio was 1.97 ± 0.39. Of the seven SLT recipients, Korean Network for Organ Sharing (KONOS) status was one in status 1, one in status 2 and five in status 3. The graft ( P = 0.72) and patient ( P = 0.84) survival rates were comparable in the SLT and WLT groups. Following propensity score matching, graft ( P = 0.61) and patient ( P = 0.91) survival rates remained comparable in the two groups. Univariate analysis showed that pretransplant ventilator support and renal replacement therapy were significantly associated with patient survival, whereas KONOS status category and primary liver diseases were not. Multivariate analysis showed that pretransplant ventilator support was an independent risk factor for patient survival. Conclusion Survival outcomes were similar in adult SLT and WLT recipients, probably due to selection of high-quality grafts and low-risk recipients. Prudent selection of donors and adult recipients for SLT may expand the liver graft pool for pediatric patients without affecting outcomes in adults undergoing SLT.

Considering extended right lobe grafts as major extended donor criteria in liver transplantation is justified

“…In contrast, non-anastomotic biliary leaks were observed only in the ERLT group and were responsible for the higher overall biliary complication rates in this group. The distribution of this complication, which is almost always of technical nature, is not surprising, because ERLT includes liver transection and higher leakage rates from the large transection plane are expected [19,43,45]. Anastomotic biliary strictures affected ERL liver recipients less than they did WLT patients.…”

“…1). Only studies that clearly described the splitting techniques, evaluated outcome of ERL liver grafts compared with WL grafts, and did not analyze overlapping collectives were eligible for analysis of ERLT and WLT outcomes [6,15,18,19,[28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45]. Despite the high quality, the study of Adam et al did not provide precise definition of the splitting liver technique and their study was therefore excluded from the analysis [46].…”

“…All included studies were retrospective cohort analyses that were published until December 2020 [6,15,18,19,[28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45]. A total of 75 799 adult transplant patients were included in the ERLT meta-analysis, with follow-up ranging from 1 to 240 months (Table 1).…”

“…The methodological index for nonrandomized studies (MINORS) criteria evaluated the quality of the included studies as low to high (Table S1). According to the MINORS criteria, four of the analyzed retrospective studies were low quality [18,32,38,47], 20 studies were intermediate quality [6,15,19,[28][29][30][31][33][34][35][36][37][39][40][41][42][43][44][45]48], and also one study was high quality [46], rendering the overall quality of the evaluated evidence as intermediate. All studies were adequately designed and the reported follow-up periods were sufficient to evaluate the endpoints of the metaanalysis.…”

“…Data was collected prospectively in six studies [19,34,37,41,42,46]. Unbiased assessment of endpoints was adequately reported in 10 studies [6,15,28,29,31,37,39,[44][45][46]. In four studies bias reports were inadequate [18,33,35,40].…”