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The Impact of Increased Allocation Priority for Children Awaiting Liver Transplant: A Liver Simulated Allocation
Emily R Perito1, Douglas B Mogul2, Douglas VanDerwerken3
1Department of Pediatrics, University of California San Francisco, San Francisco, CA.
Insights
New liver allocation strategies prioritizing children and critically ill adults significantly reduce waitlist deaths and increase transplants. SharePeds models show improved outcomes for pediatric liver transplant candidates.
Area of Science:
- Organ transplantation research
- Pediatric hepatology
- Transplant policy analysis
Background:
- Current liver allocation systems face challenges in optimizing outcomes for pediatric and critically ill adult candidates.
- The Organ Procurement and Transplantation Network (OPTN) 12-2017 allocation plan is the benchmark for comparison.
- Prioritization of specific patient groups is a key consideration in organ allocation policy.
Purpose of the Study:
- To evaluate the impact of two "SharePeds" allocation schemas on liver transplant outcomes.
- To compare the SharePeds schemas against the existing OPTN 12-2017 allocation plan.
- To determine the effect of prioritizing infants, children, adolescents, and critically ill adults (Status 1) for deceased donor livers.
Main Methods:
- Utilized the 2017 Liver Simulated Allocation Model.
- Analyzed Scientific Registry of Transplant Recipients data from July 2013 to June 2016.
- Modeled outcomes including waitlist deaths, transplants, and post-transplant deaths under different allocation schemas.
Main Results:
- SharePeds 1 (prioritizing pediatric donors for children) significantly decreased waitlist deaths for infants and children.
- SharePeds 2 (national sharing of donors <35 years for children and Status 1A adults) substantially reduced waitlist deaths across multiple pediatric and Status 1 patient groups.
- Both SharePeds schemas increased liver transplants for infants, children, and adolescents, and improved the percentage of pediatric livers transplanted into pediatric recipients.
Conclusions:
- Prioritizing pediatric donor livers for children can decrease waitlist deaths in young recipients.
- Broader national sharing of deceased donor livers, particularly for younger donors, can significantly reduce waitlist deaths and increase transplants for children and critically ill adults.
- Implementing SharePeds-like allocation strategies holds potential for improving liver transplant outcomes for vulnerable pediatric and adult populations.
Objective:
The aim of the study was to investigate the impact of prioritizing infants, children, adolescents, and the sickest adults (Status 1) for deceased donor livers. We compared outcomes under two "SharePeds" allocation schema, which prioritize children and Status 1 adults for national sharing and enhanced access to pediatric donors or all donors younger than 35 years, to outcomes under the allocation plan approved by the Organ Procurement and Transplant Network in December 2017 (Organ Procurement and Transplantation Network [OPTN] 12-2017).
Methods:
The 2017 Liver Simulated Allocation Model and Scientific Registry of Transplant Recipients data on all US liver transplant candidates and liver offers 7/2013 to 6/2016 were used to predict waitlist deaths, transplants, and post-transplant deaths under the OPTN 12-2017 and SharePeds schema.
Results:
Prioritizing national sharing of pediatric donor livers with children (SharePeds 1) would decrease waitlist deaths for infants (<2 years, P = 0.0003) and children (2-11 years, P = 0.001), with no significant change for adults (P = 0.13). Prioritizing national sharing of all younger than 35-year-old deceased donor livers with children and Status 1A adults (SharePeds 2) would decrease waitlist deaths for infants, children, and all Status 1A/B patients (P < 0.0001 for each). SharePeds 1 and 2 would increase the number of liver transplants done in infants, children, and adolescents compared to the OPTN-2017 schema (P < 0.00005 for all age groups). Both SharePeds schema would increase the percentage of pediatric livers transplanted into pediatric recipients.
Conclusions:
Waitlist deaths could be significantly decreased, and liver transplants increased, for children and the sickest adults, by prioritizing children for pediatric livers and with broader national sharing of deceased donor livers.
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