Extreme Large-for-Size Syndrome After Adult Liver Transplantation: A Model for Predicting a Potentially Lethal Complication

There is currently no tool available to predict extreme large-for-size (LFS) syndrome, a potentially disastrous complication after adult liver transplantation (LT). We aimed to identify the risk factors for extreme LFS and to build a simple predictive model. A cohort of consecutive patients who underwent LT with full grafts in a single institution was studied. The extreme LFS was defined by the impossibility to achieve direct fascial closure, even after delayed management, associated with early allograft dysfunction or nonfunction. Computed tomography scan-based measurements of the recipient were done at the lower extremity of the xiphoid. After 424 LTs for 394 patients, extreme LFS occurred in 10 (2.4%) cases. The 90-day mortality after extreme LFS was 40.0% versus 6.5% in other patients (P=0.003). In the extreme LFS group, the male donor-female recipient combination was more often observed (80.0% versus 17.4%; P<0.001). The graft weight (GW)/right anteroposterior (RAP) distance ratio was predictive of extreme LFS with the highest area under the curve (area under the curve, 0.95). The optimal cutoff was 100 (sensitivity, 100%; specificity, 88%). The other ratios based on height, weight, body mass index, body surface area, and standard liver volume exhibited lower predictive performance. The final multivariate model included the male donor-female recipient combination and the GW/RAP. When the GW to RAP ratio increases from 80, 100, to 120, the probability of extreme LFS was 2.6%, 9.6%, and 29.1% in the male donor-female recipient combination, and <1%, 1.2%, and 4.5% in other combinations. In conclusion, the GW/RAP ratio predicts extreme LFS and may be helpful to avoid futile refusal for morphological reasons or to anticipate situation at risk, especially in female recipients.