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Is Portal Inflow Modulation Always Necessary for Successful Utilization of Small Volume Living Donor Liver Grafts?

We read with interest the article by Soin et al.(1) The question posed in the article title is aptly answered by the fact that 69.77% of recipients with a graft-torecipient-weight ratio (GRWR) above 0.7% (85% of 0.75%-0.80% and 44.44% of 0.70%-0.74%) and nearly 19.44% of recipients with GRWR <0.7% did not need portal inflow modulation (PIM). From July 2018 to August 2019, we performed a hemiportocaval shunt (HPCS) procedure as PIM in 6 out of 42 right lobe living donor liver transplantations (Table 1). In a systematic review of portosystemic shunts, Kinaci and Kayaalp(2) concluded that the protective effect of shunts is not unlimited, and in patients with a GRWR <0.65%, survival decreased significantly. All mortality was in patients with a GRWR of <0.61%. However, the lowest GRWR in the study by Soin et al.(1) was 0.54% with no difference in mortality across low GRWR groups. Is a GRWR of 0.8%, thus, no longer a sacrosanct figure? If so, what GRWR should be truly low vis-à-vis recipient sickness and graft quality parameters? It would really be interesting to know about the outcomes in the left-sided grafts from the cohort of Soin et al.(1) Kaido et al.(3) in their study with a high number of left lobe grafts demonstrated that the lower limit of GRWR can be safely reduced to 0.6% using PIM. However, Tanaka and Ogura(4) showed that compared with left lobe, the influence on patient survival by graft size was small in right lobe grafts. Even in the review by Kinaci and Kayaalp,(2) 77.1% of grafts with a GRWR of <0.65% were left-sided (with a 78% 90-day mortality). So, is a low GRWR different for a right versus a left lobe graft? If not, then what about selecting low-weight, safer, left lobe donations with PIM? The protocol of Soin et al.(1) is based on actual graft weight with no mention of discordance, if any, in graft weight estimation, especially of grafts with a GRWR of <0.7%. As the authors suggest, HPCS is a more effective, modifiable, and predictable way of inflow modulation especially, more so, when GRWR is <0.7%, with a small but certain risk of portal steal. Points of caution include sepsis as the most common cause of mortality in low GRWR grafts and small-for-size-syndrome (SFSS) despite modulation (4.1%).(1)