Optimal graft size in pediatric living donor liver transplantation: How are children different from adults?

Abstract

AbstractBackgroundPediatric liver transplantation is an established treatment for end‐stage liver disease in children. However, it is still posing relevant challenges, such as optimizing the graft selection according to the recipient size. Unlike adults, small children tolerate large‐for‐size grafts and insufficient graft volume might represent an issue in adolescents when graft size is disproportionate.MethodsGraft‐size matching strategies over time were examined in pediatric liver transplantation. This review traces the measures/principles put in place to prevent large‐for‐size or small‐for‐size grafts in small children to adolescents with a literature review and an analysis of the data issued from the National Center for Child Health and Development, Tokyo, Japan.ResultsReduced left lateral segment (LLS; Couinaud's segment II and III) was widely applicable for small children less than 5 kg with metabolic liver disease or acute liver failure. There was significantly worse graft survival if the actual graft‐to‐recipient weight ratio (GRWR) was less than 1.5% in the adolescent with LLS graft due to the small‐for‐size graft. Children, particularly adolescents, may then require larger GRWR than adults to prevent small‐for‐size syndrome. The suggested ideal graft selections in pediatric LDLT are: reduced LLS, recipient body weight (BW) < 5.0 kg; LLS, 5.0 kg ≤ BW < 25 kg; left lobe (Couinaud's segment II, III, IV with middle hepatic vein), 25 kg ≤ BW < 50 kg; right lobe (Couinaud's segment V, VI, VII, VIII without middle hepatic vein), 50 kg ≤ BW. Children, particularly adolescents, may then require larger GRWR than adults to prevent small‐for‐size syndrome.ConclusionAge‐appropriate and BW‐appropriate strategies of graft selection are crucial to secure an excellent outcome in pediatric living donor liver transplantation.