Graft-to-recipient weight ratio, graft inflow modulation, and small-for-size syndrome: A multicenter prospective study from the International LDLT registry (LDLTregistry.org).
Publication/Presentation Date
10-14-2026
Abstract
Graft-to-recipient weight ratio (GRWR) is widely used to guide graft selection in living donor liver transplantation (LDLT); however, its role as an independent predictor of postoperative outcomes and small-for-size syndrome (SFSS) remains debated. Graft inflow modulation (GIM) has been increasingly adopted to allow the safe use of smaller grafts. This study evaluated the impact of GRWR and GIM on short-term outcomes using data from a prospective international registry. An analysis of prospectively collected data from the International Living Donor Liver Transplant Registry (LDLTregistry.org) was conducted, including 1944 consecutive LDLT procedures performed at 55 centers (September 2023 to February 2025). Recipients were stratified by GRWR (< 0.60%, 0.60%-0.80%, >0.80%). Primary outcomes included major postoperative complications (Clavien-Dindo ≥3a), SFSS, and 90-day mortality. Lower GRWR was associated with higher rates of major complications, SFSS, and GIM use. Overall SFSS incidence, classified according to the ILTS-iLDLT-LTSI Consensus Conference Guidelines, was 36.9%, grade B in 17.0%, and grade C in 4.0%. SFSS of any grade increased progressively with lower GRWR: 33.4% in GRWR >0.80%, 43.7% in GRWR 0.60%-0.80%, and 63.1% in GRWR < 0.60% (p< 0.001). Grade A SFSS was similar across groups (p=0.12), whereas clinically significant SFSS (grades B and C) was highest in the GRWR < 0.6% group (47.6%, p< 0.001). In all, 90-day mortality remained low (< 5%) across all groups. Nearly half of small grafts were unexpectedly small, without worse short-term outcomes. On multivariable analysis, GRWR was not associated with major complications. GRWR influences short-term outcomes after LDLT but does not fully explain SFSS risk, which appears multifactorial. These findings support a shift away from graft size as the sole determinant of risk, toward a physiology-based, lobe-specific, and standardized intraoperative approach in LDLT.
ISSN
1527-6473
Published In/Presented At
Prosperi, E., Raptis, D. A., Prosperi, E., Spiro, M., Berenguer, M., Rela, M., Broering, D. C., & and the LDLTregistry.org Collaborative (2026). Graft-to-recipient weight ratio, graft inflow modulation, and small-for-size syndrome: A multicenter prospective study from the International LDLT registry (LDLTregistry.org). Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 10.1097/LVT.0000000000001022. Advance online publication. https://doi.org/10.1097/LVT.0000000000001022
Disciplines
Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods
PubMedID
42965301
Department(s)
Administration and Leadership
Document Type
Article