Split liver transplantation and pediatric waitlist mortality in the United States: potential for improvement

Background In the United States, 1 in 10 infants and 1 in 20 older children die on the liver transplant waiting list. Increasing split liver transplantation could increase organ availability for these children, without decreasing transplants in adults. Methods Using UNOS STAR data, we identified livers transplanted 2010-2015 that could potentially have been used for split transplant, based on strict criteria. Livers not suitable for pediatric patients or allocated to high-risk recipients were excluded. Number and distribution of potentially "split-able" livers were compared to pediatric waitlist deaths in each region. Results Of 37 333 deceased donor livers transplanted, 6.3% met our strict criteria for utilization in split liver transplant. Only 3.8% of these were actually utilized for split liver transplantation. 96% were utilized for a single adult recipient. Of the 2253 transplanted as whole livers, 82% of their recipients were listed as willing to accept a segmental liver, and only 3% were listed as requiring a cold ischemia time less than 6 hours. Over the same 5 years, 299 children died on the waitlist. In every UNOS region, there were more potentially "split-able" livers than pediatric waitlist deaths. 37% of pediatric waitlist deaths occurred at transplant centers that averaged ≤1 pediatric split liver transplant annually during the study period. Conclusion This comparison, while not conclusive, suggests that we might be missing opportunities to reduce pediatric waitlist mortality without decreasing access for adults—using split liver transplant. Barriers are significant, but further work on strategies to increase split liver transplant is warranted. Corresponding Author: Emily R. Perito, MD MAS, Pediatric Gastroenterology, Hepatology, and Nutrition, 550 16th Street, 5th Floor, Box 0136; San Francisco, CA 94143, Email: emily.perito@ucsf.edu Authorship: Emily R. Perito, MD MAS: Led study design, IRB approval, data analysis and interpretation, writing and revision of the manuscript. Garrett Roll, MD: Participated in study design, data interpretation, writing and revision of the manuscript. Jennifer L. Dodge, MPH: Participated in study design, led data analysis and interpretation, participated in writing and revision of the manuscript Sue Rhee, MD: Participated in study design, data interpretation, writing and revision of the manuscript. John P. Roberts, MD: Participated in study design, data interpretation, writing and revision of the manuscript. Funding and acknowledgements: This work was supported in part by Health Resources and Services Administration contract 234-2005-37011C (UNOS Data), the NIH-NIDDK (Dr. Perito, K23 DK0990253-A101), the UCSF Liver Center (P30 DK026743), and the UCSF Department of Pediatrics (Clinical/Translational Pilot Study Grant). The data reported here have been supplied by the Minneapolis Medical Research Foundation (MMRF) as the contractor for the Scientific Registry of Transplant Recipients (SRTR). The interpretation and reporting of these data are the responsibility of the author(s) and should not be seen as an official policy of or interpretation by the SRTR or the US Government. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the NIH or the Department of Health and Human Services, nor does mention of trades names, commercial products, or organizations imply endorsement by the US Government. Disclosures: The authors of this manuscript have no conflicts of interest to disclose as described by Transplantation. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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