Left Lobe Living Donor Liver Transplantation in Adults: What Is the Safety Limit?

Small-for-size syndrome (SFSS) is the most significant cause of graft loss after living donor liver transplantation (LDLT), especially after left lobe (LL) LDLT in adults. The safety limit of applying LL-LDLT in adults without severe SFSS with a high rate of lethality needs to be determined. A total of 207 LL-LDLTs in adults since September 2005 were evaluated to analyze the risk factors for severe SFSS, defined as a serum total bilirubin concentration of >= 20.0 mg/dL after LDLT. Although there were no significant differences in cumulative graft survival after LDLT between medium grafts (graft volume [GV] to standard liver volume [SLV] ratio >= 40.0%), small grafts (35.0% <= GV/SLV < 40.0%), and extra small grafts (GV/SLV < 35.0%), patients with severe SFSS showed a significantly lower 5-year graft survival rate than those without (42.9% versus 94.3%, respectively; P < 0.001). Multivariate analysis for severe SFSS after LL-LDLT showed that donor age of >= 48 years (P=0.01), Model for End-Stage Liver Disease (MELD) score of >= 19 (P < 0.01), and end portal venous pressure of >= 19mm Hg (P=0.04) were the significant and independent factors for severe SFSS after LLLDLT. Within such high-risk subgroups of patients with a donor age of >= 48 years or MELD score of >= 19 before LDLT, operative blood loss volume of >= 8.0L was a risk factor for severe SFSS. LL-LDLT in adults could be indicated and provide acceptable outcomes for the combinations of donors aged < 48 years and recipients with a MELD score of < 19. Smaller grafts might yield acceptable outcomes in appropriately selected donor-recipient combinations.