*Purpose: Although NOTA states that organ allocation policy must recognize differences between children and adults, and adopt criteria, policies, and procedures that address the unique health care needs of children, pediatric pre-transplant mortality remains unacceptably high.

*Methods: We used SRTR data from 2017-2018 to describe (1) pre-transplant mortality among pediatric transplant candidates and (2) variation in pre-transplant mortality by age and disease severity.

*Results: Among all pediatric transplant candidates, pre-transplant mortality is highest among children waiting for lung transplant (27.3 deaths/100 WL years) followed by candidates awaiting a heart (17.6), liver (6.5), intestine (3.7) and kidney transplant (1.3) (Figure 1). Over the past decade (2007-2008 to 2017-2018), pre-transplant mortality has increased among pediatric lung candidates (12.5 to 27.3 deaths/100WL yrs), and decreased for liver (9.3 to 6.5 deaths/100WL yrs), heart (27.6 to 17.6 deaths/100 WL years), kidney candidates (2.2 to 1.3 deaths/100WL yrs) and intestine candidates (17.8 to 3.7 deaths/100WL years). Pre-transplant mortality varies by age and disease severity (Figure 2,3). Specifically, a candidate’s age or status can increase mortality rate 2-3X. Pediatric pre-transplant mortality rates are significantly higher than adults in certain groups.

*Conclusions: Despite improvement in pre-transplant mortality across organ types over time, disadvantaged subgroups within each organ type persist. Policy and practice changes should be targeted to address these specific groups.

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