Early complications after liver transplantation in children and adults: Are split grafts equal to each other and equal to whole livers?

Split-liver transplantation (LT) allows transplantation of two recipients from one deceased donor, thereby increasing pool of grafts. However, split LT may be hampered by technical problems, and split grafts are still considered suboptimal organs in some centres. We analysed the outcomes in split- and whole-liver recipients in a combined adult-to-paediatric transplantation programme. Records of paediatric and adult patients having undergone LT from 1999 to 2013 were analysed retrospectively. All splits were performed in situ. Adult split-graft recipients were matched 1:2 with whole-graft recipients (matching criteria: BMI, MELD, year of transplantation, age), and matched to the paediatric recipient transplanted from the same donor. Post-LT complications were classified according to the Clavien scale. Among children, 32 split- and 31 whole-graft recipients were analysed. Among adults, 20 split- and 40 matched whole-graft recipients were analysed. In both populations, the post-operative complications did not differ between split- and whole-graft recipients. There was no difference in 1-year graft and patient survival between split- and whole-graft recipients in paediatric (90% vs. 97%, 94% vs. 97%, respectively) and in adult recipients (89% in both, 89% vs. 92%, respectively). In the analysis of both recipients issued from the same donor, there was no association in the prevalence and severity of complications. A case-by-case analysis showed that split mortality was unrelated to LT in all but one patient (small-for-size left split graft). In the setting of careful donor selection, recipient matching and surgical skill, in situ split LT is an effective and safe technique to increase the number of available organs, and split livers should no longer considered marginal grafts.