Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: A meta-analysis

World J Gastroenterol. 2019 Sep 28;25(36):5559-5568. doi: 10.3748/wjg.v25.i36.5559.


Background: Small-for-size grafts (SFSGs) in living donor liver transplantation (LDLT) could optimize donor postoperative outcomes and also expand the potential donor pool. Evidence on whether SFSGs would affect medium-term and long-term recipient graft survival is lacking.

Aim: To evaluate the impact of small-for-size liver grafts on medium-term and long-term graft survival in adult to adult LDLT.

Methods: A systematic review and meta-analysis were performed by searching eligible studies published before January 24, 2019 on PubMed, EMBASE, and Web of Science databases. The primary outcomes were 3-year and 5-year graft survival. Incidence of small-for-size syndrome and short term mortality were also extracted.

Results: This meta-analysis is reported according to the guidelines of the PRISMA 2009 Statement. Seven retrospective observational studies with a total of 1821 LDLT recipients were included in the meta-analysis. SFSG is associated with significantly poorer medium-term graft survival. The pooled odds ratio for 3-year graft survival was 1.58 [95% confidence interval 1.10-2.29, P = 0.014]. On the other hand, pooled results of the studies showed that SFSG had no significant discriminatory effect on 5-year graft survival with an odds ratio of 1.31 (95% confidence interval 0.87-1.97, P = 0.199). Furthermore, incidence of small-for-size syndrome detected in recipients of SFSG ranged from 0-11.4% in the included studies.

Conclusion: SFSG is associated with inferior medium-term but not long-term graft survival. Comparable long-term graft survival based on liver graft size shows that smaller grafts could be accepted for LDLT with appropriate flow modulatory measures. Close follow-up for graft function is warranted within 3 years after liver transplantation.

Keywords: Graft survival; Living donor liver transplantation; Small-for-size grafts; Small-for-size syndrome.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adult
  • Age Factors
  • Allografts / anatomy & histology*
  • Allografts / supply & distribution
  • Child
  • Donor Selection / standards
  • Graft Survival*
  • Humans
  • Liver / anatomy & histology*
  • Liver Transplantation / methods*
  • Liver Transplantation / standards
  • Living Donors*
  • Organ Size
  • Practice Guidelines as Topic
  • Risk Factors
  • Time Factors
  • Treatment Outcome