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Updated: Sep 14, 2026
Heterotopic Auxiliary Rat Liver Transplantation With Flow-regulated Portal Vein Arterialization in Acute Hepatic Failure
Published on: September 13, 2014
Tailoring allocation policies and improving access to paediatric liver transplantation over a 16-year period
Marco Spada1, Roberta Angelico2, Silvia Trapani3
1Divison of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Research Unit of Clinical Hepatogastroenterology and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
Insights
Italian paediatric liver transplantation (pLT) policies, including national allocation and mandatory-split grafts, have significantly reduced waiting list mortality to near zero. These advancements ensure better outcomes for children needing liver transplants.
Area of Science:
- Hepatology and Transplant Surgery
- Pediatric Organ Transplantation
- Public Health Policy in Healthcare Allocation
Background:
- Mortality on the paediatric liver transplant (pLT) waiting list (WL) remains a significant challenge globally.
- Evaluating the intention-to-treat (ITT) success rate and identifying factors influencing outcomes are crucial for improving pLT programs.
Purpose of the Study:
- To analyze the Italian pLT waiting list (WL) data from 2002-2018.
- To assess the intention-to-treat (ITT) success rate in pediatric liver transplantation.
- To identify key factors influencing transplant success and survival rates in pediatric candidates.
Main Methods:
- Inclusion of all children (<18 years) listed for pLT in Italy between 2002-2018.
- Analysis across three eras: Era 1 (2002-2007, center-based allocation), Era 2 (2008-2014, national allocation), and Era 3 (2015-2018, national allocation + mandatory-split policy).
- Statistical analysis to determine predictive factors for receiving a transplant and for ITT survival.
Main Results:
- A total of 1,424 children were listed; 91.4% received a transplant, with 67.3% utilizing split grafts.
- Waiting list mortality was low (2.5% death, 1.0% clinical deterioration).
- Predictive factors for transplantation included higher priority status (Status 1, 1B, 2A) and PELD/MELD score; factors reducing transplant chance included higher weight (>25 kg), blood group O, and combined organ transplants. ITT survival rates were 90.5% at 1 year and 87.5% at 5 years, stable across eras. Risk factors for ITT survival included re-transplantation, higher priority status, recipient weight <6 kg, and low-volume center activity.
Conclusions:
- Continuous adaptation of Italian paediatric organ allocation policies, including national allocation, prioritization rules, and mandatory-split policy, has maximized donor utilization.
- These policy changes have effectively minimized waiting list mortality for paediatric candidates without compromising outcomes.
- The Italian model represents a significant advancement for the paediatric transplant community, achieving near-zero mortality on the waiting list.
Background & Aims:
Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success.
Methods:
All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002-2007]: centre-based allocation; Era 2 [2008-2014]: national allocation; Era 3 [2015-2018]: national allocation+mandatory-split policy).
Results:
A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7-27]) were listed for pLT. Median WL time was 2 days (IQR 1-5) for Status 1 and 44 days (IQR 15-120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p = 0.001), Status 1B (HR 1.96, p = 0.016), Status 2A (HR 2.15, p = 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p <0.001), Status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), Status 2A (HR 9.12, p <0.001), recipient weight <6 kg (HR 4.53, p <0.001) and low-volume activity (HR 4.38, p = 0.001).
Conclusions:
In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes.
Impact And Implications:
Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community.
