Introduction: Low GRWR grafts are known to associated with high rates of graft failure and small for size syndrome. Now a days portal flow is believed to be main causative factor for small for size syndrome. We present our experience of using smaller graft with portal flow modulation if portal flow is greater than 250 ml/min/100 gm of graft weight.

Materials and Methods: 450 living donor liver transplants was done during period of January 2010 to june 2013 .55 grafts with grwr less than 0.8 was used and consisit of study group. We used splenic artery ligation or spleenectomy as portal flow modulation if portal flow after reperfusion was greater than 250 ml/min/100 gm.To eliminate huge difference in sample size 130 patient were selected randomly as control group. small for size syndrome was defined according to clavian and kyushi university definations. parameters like MELD ,etiology,portal vein flow,age,sex were compared as a causative factors for small for size syndrome between two groups.statistical study were used using spss version 21.

Results: 6 patients out of 55 developed small for size syndrome in grwr < 0.8 group. There was 28 left lobe graft and 27 right lobe graft.While 16 out of 130 control group fulfilled definition of small for size syndrome. There was no statistical significant difference in graft dysfunction between low grwr group and high grwr group. In univariate and multivariate analysis Grwr was not associated with graft dysfunction. In multivariate analysis hcv etiology,Meld score and portal flow achieved statistical significance as factors associated with graft dysfunction.(p<0.05).There was no early mortality or 30 days graft loss in low GRWR group. However Lower GRWR was significantly associated with prolong ascites.

Conclusions: Lower GRWR graft with portal flow modulation in case of high portal flow is effective way to increase donor pool and donor safety with low risk of small for size syndrome. portal flow and not GRWR predicts occurrence of small for size syndrome.