A recent study (EK Hsu et al. Gastroentorol 2017; 153: 988-95, editorial 888-89) exposes some deep flaws in organ transplantation in U.S.
The retrospective study examined children on the U.S liver transplant wait-list from 2007-14. This included 3852 pediatric candidates. Key findings:
- Of 27,831 adults who underwent transplantation, 1667 (6%) received livers from pediatric donors (<18 years)
- Of children who died or were delisted, the centers caring for 173 (55%) had received an offer of 1 or more livers that was subsequently transplanted into another pediatric recipient. The remaining 45% died or delisted with no offers. High-volume (>15 transplants per year) centers were more likely to accept an organ than a low-volume center (<5 transplants per year).
- Only 29% of children received a split graft. When a splittable adult liver graft was allocated to an adult the chance of it being used as a split was 0.6%.
- Children have much lower survival rate than adults on waiting list. Of adults who died or delisted, 85% receive at least one transplant offer; whereas, nearly half of all children never even receive an offer. Children who died/delisted had wait-time of 33 days compared with 92 days for adults who died/delisted.
- Less than 10% of all liver transplant recipients are pediatric transplants. Per editorial, “a measure that improves pediatric access by 20% would only reduce adult access by 2%.”
- There are more than 100 pediatric liver transplant centers in U.S. Certainly, this improves convenience; however, per editorial: “three-fourths are very low volume centers, performing <5 liver transplantations per year…Death on waiting list” occur 5 times more at low-volume transplantation centers.
- In this study, only 29% of children received split livers; in comparison, in the UK, >80% receive either a split graft or living donor graft.
The editorial points out that splittable livers that are allocated to adults are virtually never split; this is either due to inconvenience or lack of expertise. A small increase in liver splitting would dramatically lower the pediatric mortality wait list. There is no incentive in the current system to split a liver/save a child’s life.
My take: The data from this study points out glaring problems in pediatric liver transplantation.
- Children are dying due to lack of prioritization. Pediatric livers are going to adults.
- There is practically no splitting when liver organs are allocated to an adult. Incentives to increase organ splitting would save many children from dying waiting for an organ.
- Large volume pediatric centers are much more likely to accept a liver offer for patients waiting at their centers. There is an increased wait-list mortality at very low volume centers, perhaps due to lack of expertise and passing up viable organs. Do hepatologists/surgeons at these centers explain this risk to families at their centers?
Related blog posts:
- Picking winners and losers with liver transplantation allocation
- Should Younger Transplant Patients Receive Better Organs? | gutsandgrowth
- Geographic Inequity for Liver Transplantation
- Liver Transplant Recipients Are Getting Older | gutsandgrowth
- Big gift, how much risk
- Weak Link in Liver Transplantation Survival | gutsandgrowth