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Split Liver Transplantation and Pediatric Waitlist Mortality in the United States

Potential for Improvement

Perito, Emily R., MD, MAS1,2; Roll, Garrett, MD3; Dodge, Jennifer L., MPH3; Rhee, Sue, MD1; Roberts, John P., MD3

doi: 10.1097/TP.0000000000002249
Original Clinical Science—Liver

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 United Network for Organ Sharing Standard Transplant Analysis and Research data, we identified livers transplanted 2010 to 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 used 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 United Network for Organ Sharing region, there were more potentially “split-able” livers than pediatric waitlist deaths. Thirty-seven percent of pediatric waitlist deaths occurred at transplant centers that averaged 1 or less pediatric split liver transplantation annually during the study period.

Conclusions. This comparison, although 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.

1Department of Pediatrics, University of California, San Francisco, San Francisco, CA.

2Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA.

3Department of Surgery, University of California, San Francisco, San Francisco, CA.

Received 15 February 2018. Revision received 16 March 2018.

Accepted 11 April 2018.

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.

The authors declare no conflicts of interest.

E.R.P. led the study design, IRB approval, data analysis and interpretation, writing and revision of the article. G.R. participated in study design, data interpretation, writing and revision of the article. J.L.D. participated in study design, led data analysis and interpretation, participated in writing and revision of the article. S.R. participated in study design, data interpretation, writing and revision of the article. J.P.R. participated in study design, data interpretation, writing and revision of the article.

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Correspondence: Emily R. Perito, MD, MAS, Pediatric Gastroenterology, Hepatology, and Nutrition, 550 16th Street, 5th Floor, Box 0136, San Francisco, CA 94143.

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