Higher Retransplantation Rate
Following Extended Right Split-Liver
Transplantation: An Analysis From the
Eurotransplant Liver Follow-up Registry
TO THE EDITOR:
We read with interest the article by Andrassy et al. in
Liver Transplantation on the Eurotransplant experi-
ence with extended right graft (ERG) split-liver trans-
In that series, an ex situ split was
usually performed in pediatric centers, shipping ERGs
to adult centers, resulting in prolonged cold ischemia
time (CIT), which is identiﬁed as a signiﬁcant risk
factor for graft failure. These results suggested reconsi-
dering what is the best SLT allocation policy.
The Italian SLT experience started in the mid-
1990s, and an in situ technique was chosen from the
beginning. The SLT program was initially promoted
in northern Italy and then implemented nationally,
involving both pediatric and adult transplant centers,
reaching >300 split-liver procedures in a few years
and rapidly decreasing the pediatric wait-list times
Donor age, CIT, retransplantation,
United Network for Organ Sharing (UNOS) I-IIA
status, and center volume were early ERG risk fac-
whereas in the long term, these were donor age,
donor-to-recipient weight ratio, retransplantation, and
UNOS I-IIA status.
Excellent SLT outcomes were
reported thereafter in single-center series both for left
and for ERGs
even using pediatric
The national SLT policy
enhanced in 2015: all livers from deceased adult stan-
dard risk donors aged 50 years are now mandatorily
evaluated for SLT, unless allocated to urgent patients;
if SLT is performed, centers are free to allocate the
ERG other than on the Model for End-Stage Liver
Nowadays, SLT represents almost
10% of all LTs performed in Italy versus 5% in the
Eurotransplant area and 1% in the United States; in
the last 18 months, 267 (18.1%) adult donors were
proposed for SLT and 3 (1.7%) pediatric LT candi-
dates died on the waiting list, of whom 2 children were
UNOS I status.
From our experience, an intention-to-split alloca-
tion policy, with adoption of the in situ technique and
ﬂexibility in ERG allocation, is crucial to expanding
the use of SLT and ensuring good allograft outcomes.
Roberta Angelico, M.D., F.E.B.S.
Silvia Trapani, M.D.
Michele Colledan, M.D., Ph.D., F.E.B.S.
Umberto Cillo, M.D., Ph.D., F.E.B.S.
Tullia Maria De Feo, M.D.
Marco Spada, M.D., Ph.D., F.E.B.S.
Division of Abdominal Transplantation and
Bambino Gesu Children’s Research Hospital
Istituto di Ricovero e Cura a Carattere Scientiﬁco
Italian National Transplant Center
Italian National Institute of Health
Division of Liver and Small Bowel Transplantation
Azienda Ospedaliera Papa Giovanni XXIII
Abbreviations: CIT, cold ischemia time; ERG, extended right graft;
LT, liver transplantation; SLT, split-liver transplantation; UNOS,
United Network for Organ Sharing.
Address reprint requests to Marco Spada, M.D., Ph.D., F.E.B.S.,
Division of Abdominal Transplantation and Hepatobiliopancreatic
Surgery, Bambino Gesu, Children’s Research Hospital IRCCS,
Piazza Sant’Onofrio 4, 00146 Rome, Italy. Telephone: 0039 06
68591; FAX: 0039 06 68591; E-mail: firstname.lastname@example.org
Received January 28, 2018; accepted January 29, 2018.
2018 by the American Association for the Study of Liver
View this article online at wileyonlinelibrary.com.
Potential conflict of interest: Nothing to report.
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