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Review Article

Korean J Transplant 2019; 33(4): 65-73

Published online December 31, 2019


© The Korean Society for Transplantation

Conceptual changes in small-for-size graft and small-for-size syndrome in living donor liver transplantation

Toru Ikegami1, Jong Man Kim2, Dong-Hwan Jung3, Yuji Soejima4, Dong-Sik Kim5, Jae-Won Joh2, Sung-Gyu Lee3, Tomoharu Yoshizumi1, Masaki Mori1

1Department of Surgery and Science, Kyushu University, Fukuoka, Japan;
2Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea;
3Department of Liver Transplantation and Hepatobiliary and Pancreatic Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea;
4Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan;
5Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Korea

Correspondence to: Toru Ikegami
Department of Surgery and Science, Kyushu University, Fukuoka, Japan
Tel: +81-92-642-5466, Fax: +81-92-642-5482 E-mail: tikesurg@surg2.med.kyushu-u.ac.jp

Received: December 23, 2019; Accepted: December 29, 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Early series in living donor liver transplantation (LDLT) in adults demonstrated a lower safe limit of graft volume standard liver volume ratio 25%?45%. A subsequent worldwide large LDLT series proposed a 0.8 graft recipient weight ratio (GRWR) to define small-for-size graft (SFSG) in adult LDLT. Thereafter, researchers identified innate and inevitable factors including changes in liver volume during imaging studies and graft shrinkage due to perfusion solution. Although the definition of small-for-size syndrome (SFSS) advocated in the 2000s was mainly based on prolonged cholestasis and ascites output, the term SFSS was inadequate to describe clinical manifestations possibly caused by multiple factors. Thus, the term “early allograft dysfunction (EAD),” characterized by total bilirubin >10 mg/dL or coagulopathy with international normalized ratio >1.6 on day 7, has become prevalent to describe graft dysfunction including SFSS after LDLT. Although various efforts have been made to overcome EAD in LDLT, graft selection to maintain an expected GRWR >0.8 and full venous drainage, as well as inflow modulation using splenic artery ligation, have become standard in recent LDLT.

Keywords: Living donor liver transplantation, Small-for-size graft, Small-for-size-syndrome, Early allograft dysfunction