Small‐for‐size syndrome in live donor liver transplantation—Pathways of injury and therapeutic strategies

Abstract

Due to the severe organ shortage and the increasing gap between the supply and demand for donor grafts, live donor liver transplantation (LDLT) has become an accepted and alternative technique for the expansion of the donor pool. However, donor safety and good recipient outcomes must be balanced regarding risk stratification and decision-making within this patient population. Small-for-size syndrome (SFSS) is one of the complications encountered after LDLT, thus increasing the burden of optimizing donor graft selection and effective treatments during its occurrence. A graft-to-recipient weight ratio (GRWR) <0.8 predisposes the graft to SFSS. However, other factors may induce this complication even without a graft-to-patient size mismatch. Several strategies to prevent this complication include portal vein flow and liver outflow modulation, as well as pharmacological treatment. Also, as an entity with a multifactorial etiology, outcomes vary between right-lobe, left-lobe, and posterior-lobe donation among series encountered in the literature. In this review, we analyze the pathophysiology and classification of this complication, the state-of-the-art on management of SFSS, and the outcomes regarding the best treatment strategy on this patient population.

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.…”

Liver paired exchange: Can the liver emulate the kidney?

“…There are 3 potential scenarios where hepatic mass may influence the decision to proceed with LPE: The donor allograft segment is small relative to recipient weight, and there is concern for early allograft dysfunction (EAD), also termed small‐for‐size syndrome. The donor allograft segment is too large for the recipient, which is more likely to occur with small pediatric recipients. The donor's estimated remnant hepatic volume is felt to be inadequate …”

“…felt to be inadequate. (27)(28)(29)(30)(31)(32) Although some centers are willing to use small grafts relative to recipient size with graft-to-recipient weight ratios (GRWRs) of <0.6%-0.8% and a graft weight/standard liver volume ratio of <40%, this has not been widely practiced. Some have advocated for performing a variety of graft inflow or pharmacological interventions to reduce portal flow in order to avoid EAD, but the value of such procedures/interventions are debated.…”

Morbidity and Mortality of Hepatic Right Lobe Living Donors: Systematic Review and Perspectives

“…The modulation of prostaglandin E1, nitric oxide, endothelin receptor A, adenosine 2A receptor, has been tested in animal models [43]. In 2016, Mohkam et al [44] demonstrated the preventive effect of somatostatin by decreasing portal vein flow in a porcine model of SFSS [44].…”