ABSTRACT Background Small‐for‐size syndrome (SFSS) after adult living‐donor liver transplantation (LDLT) is a poor prognostic condition. Splenectomy (Spx) has recently been reported to help prevent SFSS and improve outcomes. This study aimed to identify risk factors for SFSS that occur despite Spx at the time of LDLT. Methods This single‐center retrospective study included 973 LDLT recipients from 2001 to 2024. Of these, 577 who underwent concomitant Spx were analyzed. SFSS grading followed the 2023 International Liver Transplantation Society consensus criteria. Prognostic factors associated with SFSS grade B/C, which required perioperative portal vein inflow control, were identified. Results SFSS grade B/C occurred in 105 patients (18.2%) and was associated with significantly worse prognosis than grade 0/A (1‐year survival: 93.9% vs. 81.9%, p < 0.0001). The grade B/C group had higher levels of Model for End‐stage Liver Disease (MELD) score (median 18 vs. 15, p < 0.0001), neutrophil‐to‐lymphocyte ratio (NLR) (3.9 vs. 2.7, p < 0.0001), donor age (37 vs. 40 years, p = 0.0370), and donor body mass index (BMI) (22.7 vs. 21.8 kg/m 2 , p = 0.0093). Multivariate logistic regression identified NLR of ≥ 4.5, MELD score of ≥ 30, and donor age of ≥ 50 years, as independent predictors. Conclusions SFSS grade B/C still occurred in nearly one in five patients who underwent Spx for SFSS risk mitigation during LDLT. Patients with a high recipient NLR, MELD score, or donor age are at increased risk of SFSS despite Spx. Future strategies should emphasize careful donor selection and perioperative portal inflow modulation for high‐risk cases.
Yugawa et al. (Wed,) studied this question.