Background:The current liver allocation algorithm for livers from deceased pediatric (<18y; “pedi“) donors prioritizes adults listed locally/regionally over children listed nationally. We sought to understand pedi-liver allocation to all liver transplant (LT) candidates under this algorithm.

Methods: We examined U.S. pedi-liver allocation from 2010-2014 using UNOS STAR and Potential Transplant Recipient (PTR) data. Donor Service Areas (DSAs) with ≤25 pediatric LTs during the 5y period were classified as “Pediatric Deserts” (n=37/58).

Results: 3,318 livers from pedi-donors were transplanted into 3,482 recipients. Compared to those whose livers were transplanted in adults, pedi-donors whose livers were transplanted in children <12y were younger [3y (IQR 1-9) vs 15y (IQR 13-17)], more likely to be split (12% vs 8%), and less likely allocated within the OPO (25% vs 78%) [p<0.01 for all].

47% (1,569/3,482) of all LT recipients of pedi-livers were adults, varying from 32-66% among regions. Of these 1,569 adults, 25% (390) were transplanted with a pedi-liver that was never offered to a child; only 21% (83/390) of which were status 1A. Of these 390 pedi-livers never offered to a child, 52% (204) originated in a Pediatric Desert. Compared to adult recipients, children<12y and 12-17y received a greater % of regionally (43% and 32% vs 20%) and nationally (32% and 5% vs 2%) shared livers [p<0.01].

Compared to adults in DSAs with >25 pedi-LTs during the 5y period, a greater % of adults in Pediatric Deserts underwent LT with a pedi-liver (48% vs 42%, p<0.01). 278 children died/were delisted during the 5y study period, with a higher % occurring in Pediatric Deserts vs DSAs with >25 pedi-LTs (10% vs 6%, p<0.01). The median distance between Pediatric Deserts and a nearby DSA with a high volume pediatric LT center was 165mi (IQR 112-229).

Conclusions: 390 (12%) of all pedi-livers in 5 years were transplanted into adults before being offered to a child on the LT waitlist; 278 children died on the LT waitlist during this period. This pattern occurred more frequently with pedi-livers from Pediatric Deserts. The current LT allocation system is not equitable with regards to geography or to illness severity for pediatric LT waitlist candidates. Prioritizing national sharing of pedi-livers to children may address this inequity.

CITATION INFORMATION: Hsu E., Ge J., Bucuvalas J., Lai J. Deceased Pediatric Donor Livers: How Current Policy Drives Allocation and Transplantation Am J Transplant. 2017;17 (suppl 3).

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