title: Deceased-donor split-liver transplantation in adult recipients: is the learning curve over?
abstract: BACKGROUND
  Infants have the highest wait-list mortality of all liver transplantation candidates. Deceased-donor split-liver transplantation, a technique that provides both an adult and pediatric graft, might be the best way to decrease this disproportionate mortality. Yet concern for an increased risk to adult split recipients has discouraged its widespread adoption. We aimed to determine the current risk of graft failure in adult recipients after split-liver transplantation.
  
  
  METHODS
  United Network for Organ Sharing data from 62,190 first-time adult recipients of deceased-donor liver transplants (1995-2010) were analyzed (889 split grafts). Bivariate risk factors (p < 0.2) were included in Cox proportional hazards models of the effect of transplant type on graft failure.
  
  
  RESULTS
  Split-liver recipients had an overall hazard ratio of graft failure of 1.26 (p < 0.001) compared with whole-liver recipients. The split-liver hazard ratio was 1.45 (p < 0.001) in the pre-Model for End-Stage Liver Disease era (1995-2002) and 1.10 (p = 0.28) in the Model for End-Stage Liver Disease era (2002-2010). Interaction analyses suggested an increased risk of split-graft failure in status 1 recipients and those given an exception for hepatocellular carcinoma. Excluding higher-risk recipients, split and whole grafts had similar outcomes (hazard ratio = 0.94; p = 0.59).
  
  
  CONCLUSIONS
  The risk of graft failure is now similar between split and whole-liver recipients in the vast majority of cases, which demonstrates that the expansion of split-liver allocation might be possible without increasing the overall risk of long-term graft failure in adult recipients. Additional prospective analysis should examine if selection bias might account for the possible increase in risk for recipients with hepatocellular carcinoma or designated status 1.
authors: Department of Surgery, Boston Children's Hospital, MA.
authors: Ryan P
authors: RP
authors: Cauley
authors: Khashayar
authors: K
authors: Vakili
authors: Nora
authors: N
authors: Fullington
authors: Kristina
authors: K
authors: Potanos
authors: Dionne A
authors: DA
authors: Graham
authors: Jonathan A
authors: JA
authors: Finkelstein
authors: Heung Bae
authors: HB
authors: Kim
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D015331:Cohort Studies; D046148:Donor Selection; D005260:Female; D006085:Graft Survival; D006801:Humans; D008107:Liver Diseases / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: DD; HCC; LD; MELD; Model for End-Stage Liver Disease; UNOS; United Network for Organ Sharing; deceased donor; hepatocellular carcinoma; living donor
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