Long-Term Renal Outcomes Following Left Renal Vein Ligation Versus Direct Splenorenal Shunt Ligation in Living Donor Liver Transplantation: A 10-Year Single-Center Study

In living donor liver transplantation (LDLT), large splenorenal shunts (SRS) can divert portal inflow and negatively affect graft function due to portal steal syndrome. Direct SRS ligation (SRSL) and left renal vein ligation (LRVL) are used to prevent this complication; however, the long-term renal impact of LRVL remains unclear, particularly in recipients requiring nephrotoxic immunosuppression. We retrospectively analyzed adult LDLT recipients with large SRS (>1 cm) and normal baseline renal function who underwent SRSL (n = 120) or LRVL (n = 74). Patient and graft survival, serial renal function profiles, and tacrolimus trough levels were evaluated. Survival outcomes were comparable between the two groups. LRVL was more frequently performed in patients with higher preoperative Model for End-Stage Liver Disease (MELD) scores or increased transfusion requirements. During long-term follow-up, the LRVL group showed a more evident decline in renal function, with persistently higher serum creatinine levels, despite similar tacrolimus exposure. Four recipients in the LRVL group progressed to end-stage renal disease requiring dialysis within 10 years, whereas no dialysis cases occurred following SRSL. Although both strategies are clinically feasible, LRVL demonstrated a stronger association with progressive renal deterioration. These findings suggest that SRSL may be preferred in recipients with renal vulnerability to minimize cumulative renal burden.