Essential Updates 2024/2025 - History, Pathogenesis, Definition, Prevention, and Management of Small-for-Size Syndrome in Living-Donor Liver Transplantation

Q: What clinical features define small-for-size syndrome after LDLT?

SFSS is characterized by severe icterus (jaundice) and intractable ascites, with severity that can vary among patients.

Q: How can SFSS be managed in living-donor liver transplantation?

Management ranges from medical treatment alone to interventions such as splenic embolization; some patients may progress to graft loss or require re-transplantation.

Q: What factors are discussed as key drivers of SFSS pathogenesis?

The review highlights a temporal mismatch between hepatocyte regeneration and the regeneration of endothelial cells and bile ducts, with increased portal flow after LDLT contributing to ascites.

Sep 28, 2026

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Living-donor liver transplantation (LDLT) has become standard therapy for end-stage liver disease, but small-for-size syndrome (SFSS) remains a major challenge. SFSS is characterized by severe jaundice and refractory ascites, with variable severity. Some cases respond to medical management, whereas others need interventions such as splenic embolization and may still lead to graft loss or re-transplantation. The review summarizes SFSS grading introduced in 2003 and addresses strategies including graft selection, V5/V8 reconstruction, portal pressure and outflow optimization, and evaluation of graft quality and volume.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Introduction

Pathogenesis of SFSS

Consequences of SFSS

Annals of Gastroenterological Surgery Essential Updates 2024/2025: History, Pathogenesis, Definition, Prevention, and Management of Small-for-Size Syndrome in Living-Donor Liver Transplantation Toru Ikegami | Masashi Tsunematsu | Shinji Onda | Kenei Furukawa | Koichiro Haruki | Michinori Matsumoto | Yoshihiro Shirai Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan Correspondence: Toru Ikegami ([toruikegamijikei@jikei.ac.jp](toruikegamijikei@jikei.ac.jp)) Received: 12 May 2025 | Revised: 3 August 2025 | Accepted: 20 August 2025 Funding: This work was supported by JSPS KAKENHI, Grant Number 24K11898 . Keywords: living-donor liver transplantation | small-for-size syndrome | splenectomy ABSTRACT Although living-donor liver transplantation (LDLT) has become the standard treatment for end-stage liver disease, one of its major challenges is small-for-size syndrome (SFSS) . SFSS is characterized by severe icterus and intractable ascites, although the severity of the condition can vary. Some cases are managed with medical treatment alone, others require interventions such as splenic embolization, and some may result in graft loss or necessitate re-transplantation. A recent area of interest in this field is the new grading system introduced through collaboration between the International Liver Transplantation Society, the International Living-Donor Liver Transplantation Study Group, and the Liver Transplant Society of India in 2003. This grading system has helped define SFSS in the context of LDLT. Recent trends also include right lobe graft selection with V5/V8 reconstruction and optimal outflow to manage the high venous pressure associated with end-stage liver disease. To develop effective strategies for transplanting small-for-size grafts and preventing SFSS, it is crucial to have a comprehensive understanding of how to evaluate graft quality and volume, alongside portal pressure management, during LDLT. We review the latest literature on the pathogenesis of SFSS and the strategies for overcoming it after LDLT. 1 | Introduction Living-donor liver transplantation (LDLT) was introduced for pediatric patients in Brazil in 1989 [1], and the positive outcomes gradually established LDLT as a treatment of choice for pediatric patients with end-stage liver disease [2] . In 1993, Kawasaki et al. [3] reported in their pediatric LDLT series that a graft volumeto-standard liver volume ratio (GV/SLV) of 46% was within the safe limit. They were the first to use the term small-for-size graft (SFSG), referring to grafts with a GV/SLV of < 1.0. In 1994, the same group performed the first adult LDLT using a left lobe graft with a GV/SLV of 45%, transplanted into a small female recipient with primary biliary cirrhosis [4] . Emond et al. [5] reviewed their pediatric LDLTs using lateral segment grafts (n = 23) and adult LDLTs using left lobe grafts (n = 2) and found that five recipients who received an SFSG (defined as < 50% of the expected total liver size) showed delayed functional recovery. Additionally, a patient who received a graft comprising only 23% of the expected liver volume developed graft | Abbreviations: CT, computed tomography; EAD, early allograft dysfunction; GRWR, graft-to-recipient weight ratio; GV, graft volume; INR, international normalized ratio; LDLT, living-donor liver transplantation; MELD, Model for End-Stage Liver Disease; PGD, primary graft dysfunction; SAL, splenic artery ligation; SFSG, small-for-size graft; SFSS, small-for-size syndrome; SLV, standard liver volume. | | --- | | This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2025 The Author(s). Annals of Gastroenterological Surgery published by John Wiley

FAQs

What clinical features define small-for-size syndrome after LDLT?

SFSS is characterized by severe icterus (jaundice) and intractable ascites, with severity that can vary among patients.

How can SFSS be managed in living-donor liver transplantation?

Management ranges from medical treatment alone to interventions such as splenic embolization; some patients may progress to graft loss or require re-transplantation.

What factors are discussed as key drivers of SFSS pathogenesis?

The review highlights a temporal mismatch between hepatocyte regeneration and the regeneration of endothelial cells and bile ducts, with increased portal flow after LDLT contributing to ascites.

Sep 28, 2026

Uploaded by pixelkiddo