Deceased donor organ allocation in pediatric transplantation: A historical narrative

Abstract

Background Since the earliest clinical successes in solid organ transplantation, the proper method of organ allocation for children has been a contentious subject. Over the past 30–35 years, the medical and social establishments of various countries have favored some degree of preference for children on the respective waiting lists. However, the specific policies to accomplish this have varied widely and changed frequently between organ type and country. Methods Organ allocation policies over time were examined. This review traces the reasons behind and the measures/principles put in place to promote early deceased donor transplantation in children. Results Preferred allocation in children has been approached in a variety of ways and with varying degrees of commitment in different solid organ transplant disciplines and national medical systems. Conclusion The success of policies to advantage children has varied significantly by both organ and medical system. Further work is needed to optimize allocation strategies for pediatric candidates.

Review of pediatric combined heart‐liver transplantation: A roadmap to success

“…Although OPTN liver allocation policy as of 2020 preferentially allocates pediatric donor livers all eligible children prior to opening the candidacy to adults, this policy does not impact liver allocation in patients listed for CHLT as the heart offer pulls the liver from the same donor regardless of liver waitlist prioritization, even ahead of pediatric or Status 1A liver waitlist candidates. 19 Organ matching is an important component of pre-transplant evaluation in considering metabolic, synthetic, and functional capacity, especially in the pediatric population. Oversized donor organs may not fit into the intended recipient and can provide significant orientation challenges during implantation.…”

“…Efforts to widen the pool of available organs internationally by transplanting ABO incompatible hearts in high-risk, young (<2 years of age) patients continue to be an area of active investigation. 19 Most institutions evaluate cardiac or liver transplant candidacy based on established programmatic criteria for each individual organ, and then consider CHLT candidacy in a joint selection conference. Given that most pediatric CHLT candidates are from the CHD population, Fontan failure with relatively compensated FALD is common, which can complicate decision-making for when to proceed with HTA versus CHLT.…”

“…Adjustments to allocation policy have been made to reduce mortality risk, such as prioritizing CHD over cardiomyopathy. Efforts to widen the pool of available organs internationally by transplanting ABO incompatible hearts in high‐risk, young (<2 years of age) patients continue to be an area of active investigation 19 …”

“…Within the pediatric population, all heart prioritization statuses pull the liver offer, and all organ procurement organizations (OPOs) within 500 nautical miles must offer the liver with a primary heart offer if the patient is listed for both organs. Although OPTN liver allocation policy as of 2020 preferentially allocates pediatric donor livers all eligible children prior to opening the candidacy to adults, this policy does not impact liver allocation in patients listed for CHLT as the heart offer pulls the liver from the same donor regardless of liver waitlist prioritization, even ahead of pediatric or Status 1A liver waitlist candidates 19 …”

Offering children the best organs to optimize transplantation outcomes

“…History has so much to teach us about how to optimize pediatric access. Ettenger et al 3 share the historical context of pediatric organ allocation in the United States of America (USA) with comparisons to other systems internationally. They share the successes and failures within each organ type highlighting where work remains to reach our goals.…”