Small-for-Size Syndrome: Bridging the Gap Between Liver Transplantation and Graft Recovery

Abstract

In living donor liver transplantation, optimal graft size is estimated from values like graft volume/standard liver volume and graft/recipient body weight ratio but the final functional hepatic mass is influenced by other donor and recipient factors. Grafts with insufficient functional hepatic mass can produce a life-threatening condition with rapidly progressive liver failure called small-for-size syndrome (SFSS). Diagnosis of SFSS requires careful surveillance for signs of inadequate hepatocellular function, residual portal hypertension, and systemic inflammation that suggest rapidly progressive liver failure. Early diagnosis, symptom control, and addressing the cause of SFSS may prevent the need for retransplantation. With increased attention to avoiding donor risk, intensivists will be confronted with more SFSS recipients. In this review, we aim to outline a systematic approach to the medical management of patients with SFSS by providing a concise synopsis of general supportive care-neurological, cardiovascular, and renal support, mechanical ventilation, nutritional support, infection control, and tailored immunosuppression-with an aim to avoid end-organ damage or death and a review of current interventions including liver support devices, portal flow modulating drugs, and other experimental interventions that aim to preserve existing hepatic mass and improve conditions for hepatic regeneration. We examine evidence for SFSS interventions to provide the reader with information that may assist in clinical decision making. Points of controversy in care are purposefully highlighted to identify areas where additional experimental work is still needed. A full understanding of the pathophysiology of SFSS and measures to support liver regeneration will guide effective management.

Predictors of Radiation-Induced Liver Disease in Eastern and Western Patients With Hepatocellular Carcinoma Undergoing Proton Beam Therapy

“…In liver transplantation, graft volume less than 30% to 40% of SLV is associated with small-for-size syndrome and postoperative death. 21,38 The mortality rate could be up to 20% 39 to 21% 40 if graft volume/SLV is less than 40%. In contrast, for CP-A patients with ULV/SLV <40%, we observed the RILD-related mortality was 2% (n Z 1 of 43).…”

Mesenchymal stem cells prolong survival and prevent lethal complications in a porcine model of fulminant liver failure

“…Conservative or bridging treatment is therefore critical for FLF patients awaiting transplantation . In addition, small‐for‐size syndrome, a life‐threatening condition with rapid progression after liver transplantation, also causes FLF with unfavorable outcomes …”

“…9,12 In addition, small-for-size syndrome, a life-threatening condition with rapid progression after liver transplantation, also causes FLF with unfavorable outcomes. 13,14 Cellular therapies, in particular, the use of mesenchymal stem cells (MSCs), have been recognized as a promising therapeutic option for liver failure because of their hepatogenic differentiation potential. [15][16][17][18][19] MSCs can be harvested from a number of tissue sources including adipose tissues.…”

Facing the Ever-Changing Challenges of Caring for Cardiothoracic and Transplant Surgery Patients

“…Dr Rajakumar and colleagues have written an excellent overview of the pathophysiology and management of this condition known as small-for-size syndrome (SFSS). 12 Orthotopic liver transplantation (OLT) patients could be at significant risk for periprocedural complications. Intracardiac thrombus formation is rare, but a potentially life-threatening complication of OLT.…”

“…Dr Rajakumar and colleagues have written an excellent overview of the pathophysiology and management of this condition known as small-for-size syndrome (SFSS). 12…”