*Purpose: Low Graft recipient ratio (≤ 0.8) in adult living donor liver transplantation is considered a major risk factor affecting patient and graft survival. The aim of this study was to evaluate of adult recipients undergoing LDLT with GRWR ≤ 0.8 and compare survival to adult recipients who received larger grafts (GRWR > 0.8)

*Methods: Retrospective data of adult LDLT recipients between 1 January 2009 and 30 June 2021, was collected from the University of Pittsburgh’s Transplant Data Warehouse. Survival curves were calculated using the Kaplan- Meier method

*Results: : 446 patients underwent LDLT during the study period, of whom 59 (13.2 %) had a GRWR ≤ 0.80. There were 14 female (23.7 %) and 45 (76.3 %) recipients. The mean age was 56.2 years for female and 56.5 years for male recipients. A right lobe liver graft was used in 51 recipients (86.4%). Non alcoholic Steatohepatitis (NASH ) was the primary etiology in 17 (28.8%) and Alcoholic liver disease in 12 (20.3%) recipients. None of the recipients had a previous transplant. The mean MELD score was 18 (range 6-29).Early allograft dysfunction was noted in 20 of 59 (33.8%) recipients. No patients needed renal replacement therapy in the first week. The mean length of stay was 17 (range 5-120) days. There were 2 deaths in the first month, and 3 additional deaths in the first year. Overall one year survival was 91.5% in GRWR ≤ 0.8 group and 91.8 % in the GRWR > 0.8 group . (see graph)

*Conclusions: Smaller grafts (GRWR ≤ 0.8) can be safely used in select patients with comparable survival to larger grafts , and can potentially decrease death on the waitlist.

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