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Pediatric liver transplants require improved allocation, prioritization

Results of a retrospective study showed that pediatric patients awaiting liver transplantation who died or were delisted received a median of one pediatric liver offer. The researchers advocate that pediatric prioritization in allocation and development of improved risk stratification systems are required to reduce waitlist mortality among children.

“Pediatric providers caring for children on the liver waitlist should accept any suitable offers on their behalf, as it is unlikely they will be allocated more organs in time before their decline,” the researchers wrote. “The difference in both outcomes and offers for wait-listed children with public insurance is troubling, and suggests there are unmeasured confounders among these children that are associated with increased wait-list mortality.”

To better understand deceased donor liver offer acceptance patterns and their contribution to pediatric waitlist mortality, the researchers evaluated all liver transplant candidates aged 18 years and younger with an initial listing between May 1, 2007, and Dec. 31, 2012. Of the 3,852 patients who met inclusion criteria, 316 died or were delisted, 2,597 underwent liver transplantation, 331 were removed for clinical improvement, and 608 were censored.

There were 5,307 discrete refusals of 1,213 livers from deceased pediatric donors with a median of 3 refusals per patient (range, 1-5). Designated refusal codes included donor quality (57%), size mismatch (30%), recipient factors (7%), multi-organ transplant needed (4%), surgeon factors (0.45%) or other reason (4%). The researchers found, however, that of the 1,590 patients whose primary reason for refusal was size mismatch, approximately 50% were in range.

Of the 316 pediatric patients who died or were delisted, there was a median of one offer per patient (range, 0-2) and 173 received one or more liver offer.

Patients who received more than one offer before death or delisting were more likely to be aged younger than 1 year than those who received no offers (61% vs. 43%; P = .002). Patients aged 6 years to 11 years (15% vs. 9%; P = .002) and those aged 12 years to 17 years were more likely to die or be delisted with no offers (24% vs. 11%; P = .002).

Centers with 25 or fewer transplantations over a 5-year period comprised 17% of the pediatric patients who died or were delisted without offers. Centers with 5-year pediatric liver transplant volumes of 46 or more were more likely to have patients who died on the waitlist or were delisted with offers. Compared with less experienced centers, those with more experience were more likely to accept donors that were previously refused by a pediatric patient.

“There are [no] validated standards in the field of pediatric liver transplantation in terms of determining appropriate size-matching between donors and recipients. Indeed, half of the refusals for ‘size mismatch’ were in the ideal size range,” the researchers wrote. “These decisions are complex, and made based largely on surgeon intuition and experience, but collaborative multicenter efforts to create guidelines for organ offer decision-making could increase pediatric liver transplantation and limit variation in access to transplant across centers.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.