Selective Splenectomy Guided by Graft-to-Spleen Volume Ratio in LDLT: Liver Transplantation | April 2026

Introduction

Early allograft dysfunction (EAD) remains a major challenge after living donor liver transplantation (LDLT), often driven by portal hyperperfusion and small-for-size graft physiology. Splenectomy has been used to modulate portal flow, but its routine use is controversial due to surgical risks. The graft-to-spleen volume ratio (GSVR) has emerged as a potential physiological marker to better select patients who may benefit from splenectomy.

Problem Statement

There is no clear, objective criterion to guide selective splenectomy in LDLT. Empirical or routine splenectomy may expose patients to unnecessary risks, while omission in high-risk patients may lead to EAD, thrombocytopenia, ascites, and graft dysfunction. A reliable, reproducible strategy is needed to identify patients who truly benefit from splenic modulation.

Summary

This prospective study validated a GSVR-based selective splenectomy strategy in 141 LDLT recipients. Splenectomy was performed when GSVR ≤0.70 or in high-risk settings (ABO incompatibility, older donor, high portal pressure).