Achieving zero waitlist mortality for children on the pediatric liver transplant waitlist

Children with end-stage liver disease are at high risk of waitlist morbidity and mortality; children <1 year have the highest mortality of all age groups in the United States (US) (18.6 deaths per 100 patient-years). Pediatric candidates receive fewer offers of organs than adults, and excessive wait times contribute to delays in development that can have a lasting impact. Policy changes and outreach efforts have been insufficient to increase organ availability for children. Living donor liver transplantation (LDLT) is underutilized in the US, accounting for 14.6% of all pediatric transplants in 2023, compared with 46.2% in Canada. The ASTS Pediatric Committee therefore recommends promoting increased utilization of LDLT and incentivization and adoption of mandatory liver-splitting policies to safeguard these children, which could decrease pediatric waitlist mortality while increasing the number of liver transplants performed. Outcomes are similar between recipients of split-liver and whole-liver grafts in both pediatric and adult populations, but fewer than 5% of potentially splitable livers are currently used for split-liver transplantation in the US. In contrast, over 65% of pediatric patients in the United Kingdom receive a split-liver allograft, with excellent survival. Use of a center-based allocation system will support this mandate by reducing cold ischemia time and increasing liver availability.