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Published on: April 27, 2015
Expanding pediatric liver transplants: the role of split grafts, allocation policies, and machine perfusion
Christine S Hwang1,2, Amal A Aqul3, Yong Kyong Kwon1,2
1Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center.
Insights
Split liver transplantation (SLT) can improve access for pediatric liver transplant candidates. Implementing pediatric-first policies and machine perfusion technology can reduce waitlist mortality for children.
Area of Science:
- Hepatology
- Transplantation Surgery
- Pediatric Gastroenterology
Background:
- Pediatric liver transplant waitlist mortality is high, especially for infants.
- Split liver transplantation (SLT) improves access but is underutilized.
- Barriers to SLT adoption need to be addressed to improve outcomes.
Purpose of the Study:
- Examine barriers to split liver transplantation (SLT) adoption in pediatric liver transplantation.
- Evaluate the impact of pediatric-focused organ allocation policies.
- Assess the role of machine perfusion technology in expanding the pediatric donor pool.
Main Methods:
- Review of existing literature on SLT, allocation policies, and machine perfusion.
- Analysis of outcomes data from centers with high SLT utilization.
- Comparative analysis of international policies and their impact on waitlist mortality.
Main Results:
- SLT outcomes are comparable to whole grafts at experienced centers.
- Logistical, technical, and policy challenges limit SLT adoption.
- Pediatric-prioritized allocation and mandatory SLT policies reduce waitlist mortality.
- Machine perfusion technology shows promise for ex vivo graft splitting and reducing injury.
Conclusions:
- A multifaceted approach is needed to improve pediatric liver transplant outcomes.
- Strengthening pediatric-first allocation policies is crucial.
- Expanding SLT training and integrating machine perfusion are key strategies.
- These strategies can reduce US pediatric waitlist mortality without harming adult candidates.
Purpose Of Review:
Pediatric liver transplant waitlist mortality remains disproportionately high, particularly among infants under one year old. Despite the success of split liver transplantation (SLT) in improving pediatric access to transplants, its utilization remains limited. This review examines barriers to SLT adoption, explores the impact of pediatric-focused allocation policies, and evaluates the potential of machine perfusion technology in expanding the pediatric donor pool.
Recent Findings:
Studies have demonstrated that SLT outcomes are comparable to whole graft transplants when performed at experienced centers. However, logistical challenges, technical expertise, and policy limitations hinder its widespread adoption. Countries with pediatric-prioritized allocation and mandatory SLT policies, such as Italy and the United Kingdom, have significantly reduced pediatric waitlist mortality. Additionally, machine perfusion technology has emerged as a promising solution, allowing for ex vivo graft splitting and reducing ischemic injury, which may enhance graft utilization.
Summary:
A multifaceted approach is necessary to improve pediatric liver transplant outcomes, including stronger pediatric-first allocation policies, SLT training expansion, and integration of machine perfusion technologies. Implementing these strategies in the United States could significantly reduce pediatric waitlist mortality without negatively impacting adult transplant candidates.
