Long-Term Outcomes of Left Renal Vein Ligation in Living Donor Liver Transplantation: A 20-Year Study

BACKGROUND Persistence of large spontaneous splenorenal shunt (SSRS) can result in graft failure in adult living donor liver transplantation (LDLT) due to portal flow steal; thus, it is necessary to block SSRS to ensure sufficient portal blood flow. MATERIAL AND METHODS We performed a retrospective 20-year observational follow-up study subsequent to a prior prospective study to evaluate the long-term outcomes following ligation of the proximal left renal vein (LRV). Between October 2001 and January 2005, 44 liver cirrhosis patients underwent LDLT with LRV ligation. These patients were followed up until April 2024 or patient death. RESULTS Portal flow was significantly increased after LRV ligation. Renal function recovered uneventfully after LDLT in 40 patients. Eighteen patients died due to cancer recurrence (n=6), pneumonia (n=3), and other causes (n=9), thus 1-, 5-, 10-, and 20-year overall patient survival rates were 95.5%, 86.4%, 81.8%, and 59.1%, respectively. Solitary atrophy of the left kidney was not observed. SSRS was completely resolved in 20 patients, but the other 20 patients showed persistently identifiable SSRS of variable extents to date or at patient death. The LRV was reopened to make large SSRS in another 4 patients, in which retrograde transvenous obliteration was performed in 2 for variceal bleeding control and in another 2 for portal flow augmentation. CONCLUSIONS This study demonstrated that LRV ligation is a safe and effective method to control SSRS. Currently, direct ligation of the SSRS is preferred, but LRV ligation still can be a good therapeutic option when direct access to SSRS is not feasible.