Higher risk of posttransplant graft failure in male recipients of female donor grafts might not be due to anastomotic size disparity

ABSTRACTBackgroundPosttransplant liver graft failure occurs most often in male recipients of livers from female donors. The respective role of donor sex itself and the size disparity in graft vessels/bile ducts according to donor sex are unclear. Thus, we aimed to evaluate the importance of donor sex with adjustment for anastomotic size disparity between female and male donor grafts.MethodsA total of 309 male patients without hepatic tumors who underwent living donor liver transplantation were analyzed (109 female and 200 male donors). The primary outcome was posttransplant graft failure (ie, retransplantation or death). Survival analysis was performed using the Cox model. Analyzed anastomosis-related factors comprised graft weight, number and size of hepatic vessels/bile ducts, and anastomosis techniques.ResultsGraft failure probabilities at 1, 6, 12, 24, and 60 months posttransplantation were 9.1%, 19.5%, 20.2%, 23.0%, and 27.0%, respectively, with female donors and 2.0%, 5.5%, 8.1%, 10.1%, and 13.5% with male donors (HR=2.29 [1.35–3.88], P=0.002). Multivariable analysis confirmed the significance of donor sex (HR=2.30 [1.14–4.67], P=0.021) after adjustment for anastomosis-related factors. All analyzed anastomosis-related factors showed no significant association with graft failure, although size of the graft hepatic artery showed marginal significance (HR=0.50 [0.25–1.01], P=0.053). The significance of donor gender was lost when donor age was >36–40 years (age of poor ovarian reserve and end of fertility). Our institutional pediatric recipient cohort validated the inferiority of female-to-male donation.ConclusionsDonor sex appears to be an independent factor modulating graft failure risk in male liver transplant recipients. Background Posttransplant liver graft failure occurs most often in male recipients of livers from female donors. The respective role of donor sex itself and the size disparity in graft vessels/bile ducts according to donor sex are unclear. Thus, we aimed to evaluate the importance of donor sex with adjustment for anastomotic size disparity between female and male donor grafts. Methods A total of 309 male patients without hepatic tumors who underwent living donor liver transplantation were analyzed (109 female and 200 male donors). The primary outcome was posttransplant graft failure (ie, retransplantation or death). Survival analysis was performed using the Cox model. Analyzed anastomosis-related factors comprised graft weight, number and size of hepatic vessels/bile ducts, and anastomosis techniques. Results Graft failure probabilities at 1, 6, 12, 24, and 60 months posttransplantation were 9.1%, 19.5%, 20.2%, 23.0%, and 27.0%, respectively, with female donors and 2.0%, 5.5%, 8.1%, 10.1%, and 13.5% with male donors (HR=2.29 [1.35–3.88], P=0.002). Multivariable analysis confirmed the significance of donor sex (HR=2.30 [1.14–4.67], P=0.021) after adjustment for anastomosis-related factors. All analyzed anastomosis-related factors showed no significant association with graft failure, although size of the graft hepatic artery showed marginal significance (HR=0.50 [0.25–1.01], P=0.053). The significance of donor gender was lost when donor age was >36–40 years (age of poor ovarian reserve and end of fertility). Our institutional pediatric recipient cohort validated the inferiority of female-to-male donation. Conclusions Donor sex appears to be an independent factor modulating graft failure risk in male liver transplant recipients. Correspondence: Han S, Department of Anesthesiology and Pain Medicine, Samsung Medical Center, 81 Irwon-ro, Gangnam, Seoul 06352, Korea. Tel.: +82-2-3410-2470; Fax: +82-2-3410-2461; E-mail: sangbin.han@samsung.com Conflicts of Interest and Source of Funding: Nothing to report Ethics committee of the Samsung Medical Center, identifier SMC 2017-05-054. Conflict of interest: The authors of this manuscript declare no conflict of interest. Funding source: No external fund received. Authorship Kyo Won Lee designed the study, collected data, analyzed data, and wrote the manuscript E-mail: kw1980.lee@samsung.com Sangbin Han designed the study, collected data, interpreted data, and wrote the manuscript E-mail: sangbin.han@samsung.com Sanghoon Lee interpreted data, gave statistical advice, and provided critical revisions E-mail: sanghoone.lee@samsung.com Hyun-Hwa Cha interpreted data, gave statistical advice, and provided critical revisions E-mail: chh9861@hanmail.net Soohyun Ahn interpreted data, gave critical revisions, and wrote the manuscript E-mail: soohyun63.ahn@samsung.com Hyeon Seon Ahn collected data, interpreted data, and gave critical revisions E-mail: hs.ahn@sbri.co.kr Justin S. Ko collected data, analyzed data, and wrote the manuscript E-mail: jsko@skku.edu Mi Sook Gwak contributed to conception, interpreted data, and gave critical revision E-mail: gwakms@skku.edu Gaab Soo Kim contributed to conception, acquisition of data, and interpretation of data E-mail: gskim@skku.edu Jae-Won Joh contributed to conception, acquisition of data, and revisions E-mail: jwjoh@skku.edu Suk-Koo Lee contributed to conception, acquisition of data, and revisions E-mail: sukkoo.lee@samsung.com Gyu-Seong Choi designed the study, collected data, and gave critical revisions E-mail: med9370@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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