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Split Liver Transplantation In Adult Recipients: Is The Learning Curve Over?
Ryan Cauley MD1, Nora Fullington MD1, Kristina Potanos MD1, Jonathan A Finkelstein MD MPH2, Dionne Graham PhD3, Khashayar Vakili MD1, Heung Bae Kim MD1
1Department of Surgery, Boston Children's Hospital, Boston, MA 2Department of Pediatrics, Boston Children's Hospital, Boston, MA 3Clinical Research Center, Boston Children's Hospital, Boston, MA

Background: Although utilization of split liver transplantation has the potential to improve organ availability for children, historic data showing increased risk to adult recipients have discouraged their use. We aimed to determine the current risk of graft failure in adult recipients of split liver transplantation. Methods: United Network for Organ Sharing (UNOS) data from 62,252 first-time adult recipients of deceased-donor liver transplants (1995-2010) were analyzed (889 split grafts). Multiorgan recipients, and transplants from donors after circulatory death and living donors were excluded. Potential risk factors identified on bivariate analyses (p<0.2) were included in a propensity score-adjusted proportional hazards model of the effect of transplant type on graft failure. Results: Split liver transplant recipients had an over-all hazard ratio (HR) of graft failure of 1.25 (p<.001) compared to whole liver transplant recipients. The split graft HR was 1.32 (p<.001) in the pre-MELD era, and 1.18 (p=.06) post-MELD. Subset analyses suggested an increased risk of split graft failure in patients listed as Status 1 or given an exception for hepatocellular carcinoma (HCC). Excluding these higher-risk recipients, split and whole grafts had similar outcomes (HR .98, p=.76). Conclusion: The unadjusted hazard of graft loss following split transplant appears to have decreased in the post-MELD era. Excluding recipients with an HCC exception or those listed at Status 1, the risk of graft loss is similar between split and whole livers in the post-MELD era - suggesting that increasing utilization of split liver donors for children may be possible while minimizing risk to adult recipients.


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