Portal vein pressure modulation in adult living donor liver transplant: a necessity for achieving better outcomes

Background Living donor liver transplantation was first introduced as an alternative to deceased donor liver transplantation. In adult living donor liver transplantation (ALDLT), it is inevitable that the graft would be smaller than the native liver. However, if the graft function is not sufficient to satisfy the metabolic needs of the recipient, small-for-size syndrome (SFSS) can be encountered. Elevated portal vein pressure (PVP) is believed to be a main contributor in the pathophysiology of the SFSS. Therefore, we analyzed the potential effect of PVP on the outcomes in ALDLT in this study. Patients and methods Data were gathered prospectively for patients who underwent ALDLT with PVP monitoring during the period between June 30, 2018, and June 30, 2020, in Kyoto University Hospital. As a result, 36 patients were enrolled in our study. Modulation was done by splenectomy (SPX) when graft weight-to-recipient spleen volume ratio was less than or equal to 0.7 g/ml or PVP after graft reperfusion was more than 15 mmHg when graft was obtained from older or ABO incompatible donors. Results With this modulation strategy, SFSS was not encountered, and overall survival was 100%. High final PVP tended to be encountered in smaller graft weight, lower donor BMI, and left lobe grafts. Graft weight-to-spleen volume ratio less than 0.64 g/ml was an independent risk factor for high PVP after graft reperfusion. SPX was safely done with no difference in complications, postoperative platelet count was higher, and daily ascites amount was lower in patients who underwent SPX. Conclusion PVP monitoring and modulation is a necessity for good outcomes after ALDLT.