Objectives:

Efforts to reduce the risk of donor hepatectomy have resulted in smaller grafts for transplantation. Grafts below 0.8% of recipient body weight (GW/RW), have been defined as SFS and have traditionally had worse outcomes. Reduction of excess portal flow (PF) may be protective of graft injury in SFS LDLT though there is no consensus on the indications for and the results of PM. Three related issues need to be clarified, the relation of hepatic hemodynamics to graft size, the efficacy of PM to improve hepatic flows, and the relationship of HD to graft function and outcomes. In this study we sought to define the relationship between HD and graft outcomes, and determine the effect of PM.

Methods:

70 LDLT between Sep.2009 and Jul.2015 were enrolled in a single center cohort study of HD and PM. 34 were right lobes and 36 were left lobes with GW/BW ranging from 0.47% to 4.63%. 30 subjects (43%) had GW/BW <.08. PM was performed in 21 (33%). Outcome variables included function (day 7 bilirubin), ascites formation, and graft survival.

Results:

After reperfusion hepatic artery flow (HAF) was (162.7±157.6) ml/min, PF was (1179.5±719.3)ml/min and portal pressure (PP) was (14.8±5.2)mmHg. Mean PP was 13±4 in subjects without PM and 19.3±4.9 in subjects with PM (P=0.0001). After PM (n=21), there was 30%±14 reduction in PP, a 35%±19 decrease in PF and a 38%±24 increase in HAF.Graft function was assessed with respect to final HD after all modulations. Functional consequences of HD were observed when GW/BW was below 0.8%. Further analysis was conducted to identify cut-off values for final HD associated with significant changes in postoperative graft function. In subjects with GWRW < 0.8%, day 7 bilirubin was significantly higher when final PP >11 mmHg; (7.4±6.4 vs 2.3±2.3 p= .032) and final HAF below .25ml/gm.(P=.01). Graft survival not different based on graft size; 83.3% when GW/BW <0.8 and 82.5% in GW/BW >0.8.

Conclusion:

Our findings demonstrate expected results of PM when performed in a single center with a consistent approach. HD at the end of the procedure were correlated with functional assessment of graft function. In this setting SFS were used with survival comparable results to larger grafts. A larger cohort using a defined protocol will be needed to validate these observations.

CITATION INFORMATION: Mansour T, Pisa J, Przybyszewski E, Guarrera J, Tomoaki K, Samstein B, Halazun K, Griesemer A, Emond J. Hepatic Hemodynamics (HD) and Portal Flow Modulation (PM): Tactical Use in Small for Size (SFS) Live Donor Liver Transplantation (LDLT). Am J Transplant. 2016;16 (suppl 3).

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