*Purpose: Assessing composite outcome measures are critical when evaluating graft type selection in pediatric liver transplantation (LT).

*Methods: OPTN data on children listed for first-time LT or liver-kidney transplant from 11/2004- 9/2020 was analyzed and grouped by center code. Centers performing < 10 LT or with < 5 children waitlisted over the study period were excluded. Variance was plotted in terciles spanning the min and max of center metrics: LT volume, waitlist mortality, and rate of technical variants (TV, deceased and living donor), and of graft and recipient death within 1yr post-TX. Center metrics were analyzed for their association with center waitlist mortality and patient survival with univariate linear and Cox proportional hazard regressions.

*Results: From 2004-20, 63 centers performed 7563 LT; 935 children died on the waitlist. Waitlist mortality by center ranged from 0-22% (p < .00) and center TX volume, and graft outcomes by terciles are shown in Figure 1. Centers with higher waitlist mortality have significantly lower rates of TV graft use and lower rates of recipient and graft survival for children that reach LT. Survival from waitlisting to death was significantly higher with increased center usage of any TV graft among other center-specific metrics. Rate of TV use varied widely across pediatric LT centers, but overall those with TV usage rates in the lower 50% accounted for the majority of centers with higher waitlist mortality (Figure 2).

*Conclusions: Waitlist death rate and TV usage varies dramatically among pediatric LT centers in the US; > 10% of children continue to die awaiting LT. Centers with increased TV graft usage have significantly lower waitlist mortality and higher patient survival. Evaluating graft selection practices of high performing centers can better inform training and center practices and help develop organ graft type decision support tools in pediatric LT.

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