*Purpose: In living donor liver transplantation (LDLT), various risk factors have been identified among both recipient and donor factors, such as Model for End-Stage Liver Disease (MELD) score, hepatitis C, graft size, donor age and steatosis. Previously, we reported the prognostic value of D-MELD (donor age × MELD), as a combination index of recipient and donor risk factors in adult-to-adult LDLT. This study aimed to identify prognostic factors and predict the outcomes of adult-to-adult LDLT, paying attention to graft factors.

*Methods: Among 126 patients who underwent adult-to-adult LDLT from March 2002 to May 2018, we evaluated 117 recipients in whom graft factors could be assessed. Recipient, donor and graft factors were analyzed in multivariate analysis to find prognostic factors for overall survival (OS).

*Results: In multivariate analysis for OS, MELD score, GRWR (graft-to-recipient weight ratio) and hepatitis C virus (HCV) infection were independent prognostic factors. From these findings, we devised a new prognostic index MELDGR (MELD score/GRWR ratio). We identified most appropriate cut-off value of MGRWR for OS as 30.24 using Cutoff Finder (Budczies et al. 2012). According to the MELDGR, these 117 recipients were divided into the two groups: Low-MELDGR group (n=95): MGRWR ≤30 and High-MELDGR group (n=22): MGRWR >30, and the patient background and surgical outcomes were compared between the two groups. The rate of Child-Pugh C (100% vs 44%, p<0.001), acute hepatic failure (27% vs 6%) and decompensated liver cirrhosis (50% vs 28%) were significantly higher in High-MELDGR group than in Low-MELDGR group (p=0.001). The rate of vascular complication (46% vs 19%, p=0.009), total bilirubin level on postoperative day 14 (10.6 vs 3.3 mg/dl, p<0.001) and 90-day mortality (36% vs 14%, p=0.026) were significantly higher in High-MELDGR group than in Low-MELDGR group. OS was significantly lower in High-MELDGR group than in Low-MELDGR group (5-year survival: 34% vs 71%, p=0.0002). In subgroup analysis, OS of High-MELDGR group was significantly lower also in HCV positive (5-year survival: 25% vs 53%, p=0.013), non-B non-C (5-year survival: 27% vs 78%, p=0.002), HCC (5-year survival: 0% vs 70%, p=0.013) and non-HCC patient groups (5-year survival: 37% vs 72%, p=0.013).

*Conclusions: In adult-to-adult LDLT, MELDGR, the product from MELD score and GRWR, was a useful index to predict early and long term patient survival. We should use larger size graft for the recipients with poor preoperative condition with high MELD score.

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