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Portal pressure <15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before

To prevent small‐for‐size syndrome in adult‐to‐adult living donor liver transplantation (A‐LDLT), larger grafts (ie, right lobe grafts) have been selected in many transplant centers. However, some centers are investigating the benefits of portal pressure modulation. Five hundred sixty‐six A‐LDLT procedures using right or left lobe grafts were performed between 1998 and 2008. In 2006, we introduced intentional portal pressure control, and we changed the graft selection criteria to include a graft/recipient weight ratio >0.7% instead of the original value of >0.8%. All recipients were divided into period I (1998‐2006, the era of unintentional portal pressure control; n = 432) and period II (2006‐2008, the era of intentional portal pressure control; n = 134). The selection of small‐for‐size grafts increased from 7.8% to 23.9%, and the selection of left lobe grafts increased from 4.9% to 32.1%. Despite the increase in the number of smaller grafts in period II, 1‐year patient survival was significantly improved (87.9% versus 76.2%). In 129 recipients in period II, portal pressure was monitored. Patients with a portal pressure <15 mm Hg demonstrated better 2‐year survival (n = 86, 93.0%) than patients with a portal pressure ≥15 mm Hg (n = 43, 66.3%). The recovery from hyperbilirubinemia and coagulopathy after transplantation was significantly better in patients with a portal pressure <15 mm Hg. In conclusion, our strategy for A‐LDLT has changed from larger graft–based A‐LDLT to controlled portal pressure–based A‐LDLT with smaller grafts. A portal pressure <15 mm Hg seems to be a key for successful A‐LDLT. Liver Transpl 16:718‐728, 2010. © 2010 AASLD.