*Purpose: Despite major improvement in medical and nutritional care of pediatric patients suffering from intoxication inherited metabolic disorders, their long term outcomes remain guarded. Liver transplant (LT) can improve quality life and longevity for such patients, even if they do not have primary liver involvement. As a results there has been a paradigm shift in the treatment modalities of metabolic disorders to include liver transplantation. This new treatment trend is changing the face of pediatric liver transplantation. We propose to examine the effect of this treatment paradigm change on a large pediatric transplant program.

*Methods: A retrospective study was conducted inclusive of all pediatric liver transplants conducted at the MedStar Georgetown University Hospital between January 2012 and Dec 2017. We evaluated program volume growth, age at transplantation, and effect on non-metabolic patients (PLD) on the wait list . The T-test was used for statistical analysis.

*Results: A total of 105 patient received LT during the study period. We noted an absolute growth in metabolic patients recipients, as well as an increase in their overall proportion in our recipient population (from 29% to 54%). While the median age at transplant in non-metabolic patients remained stable, we saw a significant progressive decrease in the median age at transplantation over time in the metabolic patients. This result reflects a trend towards accepting transplantation at a younger age for brain protection. To address the question of possible negative effect of the metabolic patients on organ access of the PLD patients, we looked at PELD scores of the metabolic kids vs the rest of our population and at their respective transplant wait times. In our program, metabolic patients had similar average PELD scores as PLD patients making the urgency for liver transplantation comparatively high. The wait time to transplantation was also statistically similar between metabolic and PLD patients. (148 d vs 98d).

*Conclusions: Since the implementation of a metabolic transplant program, the absolute numbers and proportion of metabolic liver recipients have increased as the paradigm of metabolic transplantation took hold. In our current allocation system, the growth of the metabolic program did not negatively affect our PLD wait time, likely because of a focused effort in our program to implementation domino transplantation, living donation, and anatomic variant cadaver transplantation, expanding our organ pool and transplantation efficiency.

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