Comparative Outcomes of Split versus Whole Liver Transplantation in Adult ESLD Recipients: A Multicenter Propensity-Matched Analysis

This multicenter study (2018–2022) compared split liver (SLT) vs. whole liver (WLT) transplantation in 5,978 adults (1,532 SLT; 4,446 WLT). Propensity-matched analysis showed HCC-SLT recipients had higher early allograft dysfunction (25.7% vs. 16.8%, P < 0.001) and pleural effusion (17.3% vs. 9.9%, P < 0.001) than HCC-WLT, while non-HCC ESLD-SLT recipients faced more intra-abdominal bleeding (13.5% vs. 8.5%, P = 0.02) and vascular complications (4.7% vs. 1.9%, P = 0.01). Despite these early risks, HCC cohorts achieved equivalent 5-year overall (OS) and disease-free survival (P > 0.05). Non-HCC ESLD recipients with right hemiliver/trisection grafts had superior 1-/3-year OS (82.2%/77.2% vs. 63.4%/57.8%, P < 0.001) versus left hemiliver. Multivariate analysis identified donor BMI, MELD > 25, prolonged cold ischemia time (CIT), and exceeding Milan/Hangzhou criteria as HCC survival risks; age, CIT, and graft type predicted non-HCC mortality. SLT offers oncologically safe, long-term outcomes for HCC comparable to WLT with strict selection, while right-graft optimization and CIT reduction improve non-HCC ESLD survival.