Global lessons in graft type and pediatric liver allocation: A path toward improving outcomes and eliminating wait‐list mortality

Abstract

Current literature and policy in pediatric liver allocation and organ procurement are reviewed here in narrative fashion, highlighting historical context, ethical framework, technical/procurement considerations, and support for a logical way forward to an equitable pediatric liver allocation system that will improve pediatric wait-list and posttransplant outcomes without adversely affecting adults. Where available, varying examples of successful international pediatric liver allocation and split-liver policy will be compared to current US policy to highlight potential strategies that can be considered globally. Adaptation of longterm immunosuppressive regimens and developments in medical care and surgical techniques have contributed to >90% longterm patient and graft survival for pediatric liver transplant recipients. However, several areas of concern remain including mortality on the waiting list in young candidates and variable wait times. As we strive for better quality of survival, pediatric providers are compelled to recognize that mortality is not the only issue of concern as chronically ill children linger on the waiting list. Longterm morbidity of increased pediatric wait-list times and decreased rates of transplantation may compromise physical, neurological, and social development. Timely transplantation in children will not only reduce mortality but has the potential to improve quality of life and lower societal burden.

Monitoring intra‐abdominal pressure after liver transplantation in children

“…Additionally, graft volume should be well‐matched to the recipient's abdomen size to prevent impairment of blood supply and graft dysfunction associated with abdominal compartment syndrome . Surgeons perform TAC with patch enlargement of the abdominal cavity when split adult‐liver grafts are too large to fit within the abdominal cavity of small patients without leading to pressurization of the organ . TAC was applied in 78% of children with a mean time until final abdominal closure (Table ) consistent with times in previously published case series .…”

“…Pediatric LTX is an established procedure for children with end‐stage liver disease or congenital metabolic disorders. Because the majority of pediatric patients requiring LTX are younger than 1 year old and there are few pediatric donor organs available, partial adult organs are often used . A size mismatch between a small abdominal cavity and a relatively large split organ in small children can lead to traction and insufficient compliance of the abdominal wall, a circumstance that has the potential to produce high IAP.…”

Expansion of the Liver Donor Supply Through Greater Use of Split‐Liver Transplantation: Identifying Optimal Recipients

“…Wait‐listed children typically receive fewer offers for deceased donor organs than adults, suggesting that they are especially vulnerable to an imbalance in need and availability . Consequently, neonates have the highest rate of wait‐list mortality for any age group with nearly one‐third of wait‐listed neonates dying before receiving a suitable offer …”

Analysis of Liver Offers to Pediatric Candidates on the Transplant Wait List

“…11 In the international experience, particularly in the United Kingdom, Brazil, and Eurotransplant countries, when children are given priority for adult organs, there are increased transplantation rates, increased organ utilization through the use of splitting, and improved long-term outcomes for all children on the wait-list. 12–15 The effects of a change in US allocation policy to allow for national sharing of pediatric donor organs after local allocation to status 1A adults should be modeled to predict the effects on organ utilization rate for liver splitting and technical variant grafts, as well as both pediatric and adult liver wait-list outcomes.…”