*Purpose: Greater distance from transplant center in adult liver transplant (LT) candidates is associated with increased waitlist mortality. Pediatric LT candidates have higher waitlist mortality compared to adults, and geographic disparity has not been assessed in this vulnerable population.

*Methods: SRTR data was used to study pediatric (<18 years) LT candidates listed between 2016-2020. Candidate home and transplant center ZIP codes were merged from the 2021 US Census. Distance between ZIP codes was calculated using the Vincenty’s Formula and stratified into cohorts based on a cutoff of 500 miles. A Cox regression model adjusted for race/ethnicity, insurance type, primary disease diagnosis, allocation MELD, and listing status 1A was used to assess the association between distance from transplant center and waitlist mortality.

*Results: 2643 pediatric LT candidates with available ZIP codes were included. Median (IQR) age was 2 (0-9) years; 49% were male and 47% white. The most common primary diagnosis was biliary atresia (38%). Pediatric LT candidates were on the waitlist for median (IQR) 68 (20-171) days. Median (IQR) distance from transplant center was 51 (17-149) miles. 137 (5.2%) candidates were ≥500 miles from their transplant center. ≥500 miles compared to <500 miles candidates were more likely to have private insurance (p<0.001), but did not significantly differ in demographics, allocation MELD, or disease diagnosis. 76% of ≥500 miles candidates were transplanted in CA, OH, PA, and TX, while <500 miles candidates tended to be transplanted uniformly throughout the US. 9 (6.6%) ≥500 miles and 115 (4.6%) <500 miles candidates died while waitlisted for transplant. Unadjusted cumulative mortality at 6 months, 1 year, and 3 years was 9.9%, 9.9%, 22.7% for ≥500 miles and 6.8%, 8.1%, 10% for <500 miles candidates. In an adjusted model, living ≥500 miles from transplant center was associated with a 2-fold increased waitlist mortality compared to being <500 miles (aHR=2.32 [1.15-4.67], p=0.018) (Figure).

*Conclusions: Living a substantial distance from a transplant center is associated with inferior waitlist survival among pediatric LT candidates. However, the majority of ≥500 miles candidates were transplanted in four key states, suggesting candidate and family willingness to travel for big name, high-volume centers. Transplant centers should continue to offer and develop strategies to ensure timely access and continuity of care among this subgroup.

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