Building Equity Through Experience: Insights From 1560 Single-Center Pediatric Liver Transplants in a Developing...

Area of Science:

• Hepatology
• Transplant Surgery
• Pediatric Gastroenterology

Background:

• A single transplant center in São Paulo, Brazil, has accumulated extensive experience in pediatric liver transplantation (PLT) over 34 years.
• The center has performed 1560 PLTs, including living donor liver transplants (LDLT), deceased donor liver transplants (DDT), and domino procedures.
• Recent outcomes in a cohort of 500 PLTs (2018-2024) demonstrate high 1- and 5-year patient survival rates of 96.7% and 94.8%.

Purpose of the Study:

• To report the long-term outcomes and experience of a high-volume pediatric liver transplant program in a low- and middle-income country.
• To highlight the center's significant contribution to PLT in Brazil, particularly for young children.
• To identify and discuss key barriers to sustainable and equitable PLT development in Brazil and propose guiding principles.

Main Methods:

• Retrospective analysis of pediatric liver transplant data from a single center over 34 years.
• Detailed review of patient survival rates and procedure types, including LDLT, DDT, and domino procedures.
• Analysis of the center's contribution to national PLT statistics and identification of systemic challenges.

Main Results:

• Over 34 years, 1560 pediatric liver transplants were performed, with 1352 LDLT, 179 DDT, and 29 domino procedures.
• In the most recent cohort (2018-2024), 1- and 5-year patient survival rates were 96.7% and 94.8%, respectively.
• The center performed 35.1% of all PLTs in Brazil from 2015-2024, and 45.5% of those in children under 5, with 98.1% utilizing LDLT.

Conclusions:

• Excellent long-term outcomes in pediatric liver transplantation are achievable even in resource-constrained settings.
• Significant structural challenges, including underfunding and access disparities, hinder equitable PLT development in Brazil.
• Institutional commitment, strategic investment, and national coordination are crucial for advancing pediatric liver transplantation and ensuring equitable access.