In stark contrast to short-term survival, there have been no appreciable improvements in long-term survival following liver transplantation among 1-year survivors. Long-term sequelae of immunosuppression, including malignancy and infection, are the most common causes of death. This study highlights the need for better long-term immunosuppression management.

Background The clinical course of COVID‐19 in pediatric solid organ transplant recipients remains ambiguous. Though preliminary experiences with adult transplant recipients have been published, literature centered on the pediatric population is limited. We herein report a multi‐center, multi‐organ cohort analysis of COVID‐19 positive transplant recipients ≤ 18 years at time of transplant. Methods Data were collected via institutions’ respective electronic medical record systems. Local review boards approved this cross‐institutional study. Results Among 5 transplant centers, 26 patients (62% male) were reviewed with a median age of 8 years. 6 were heart recipients, 8 kidney, 10 liver, and 2 lung. Presenting symptoms included cough (n=12 (46%)), fever (n=9 (35%)), dry/sore throat (n=3 (12%)), rhinorrhea (n=3 (12%)), anosmia (n=2 (8%)), chest pain (n=2 (8%)), diarrhea (n=2 (8%)), dyspnea (n=1 (4%)), and headache (n=1 (4%)). Six patients (23%) were asymptomatic. No patient required supplemental oxygen, intubation, or ECMO. Eight patients (31%) were hospitalized at time of diagnosis, 3 of whom were already admitted for unrelated problems. Post‐transplant immunosuppression was reduced for only 2 patients (8%). All symptomatic patients recovered within 7 days. Conclusions Our multi‐institutional experience suggests the prognoses of pediatric transplant recipients infected with COVID‐19 may mirror those of immunocompetent children, with infrequent hospitalization and minimal treatment, if any, required.

he deficit of donor livers for transplant in the United States is growing. In 2000, there were 12 000 more patients on the liver transplant waiting list than the number of patients who actually received liver allografts. 1 At present, half of the patients awaiting liver transplant will not receive an allograft. 2 In 2016, more than 20% of liver allografts from deceased donors intended to be transplanted were discarded. 3 These discarded allografts are the most accessible source of organs to bridge this unmet need. More aggressive use of these allografts will tap into this existing source of donors and holds the most promise for increasing the chance for transplantation for patients awaiting transplant and decreasing death while on the waiting list.In 2016, approximately 1600 liver allografts 3 were discarded. Reduction of this discard rate could be accomplished by more aggressive transplant of "marginal" allografts, as they are defined today. These marginal allografts historically demonstrated worse allograft and patient outcomes compared with nonmarginal allografts. Comprehensive center-level studies indicate that wider acceptance of marginal allografts bolsters donor supply and, more importantly, reduces waiting list mortality. 4 More zealous use of marginal allografts is associated with increasing transplant center volume, possibly owing to the widening chasm between the number of patients on the waiting list and available allografts. [5][6][7][8] Use of marginal allografts has been shown to demonstrate similar short-term outcomes as nonmarginal allografts while also reducing candidate time on the waiting list. [9][10][11] Investigating outcomes of these marginal allografts is essential to understanding how they can be used most effectively. IMPORTANCE Investigating outcomes after marginal allograft transplant is essential in determining appropriate and more aggressive use of these allografts.OBJECTIVE To determine the time trends in the outcomes of marginal liver allografts as defined by 6 different sets of criteria. DESIGN, SETTING, AND PARTICIPANTSIn this cohort, multicenter study, 75 050 patients who received a liver transplant between March 1, 2002, and September 30, 2016, were retrospectively analyzed to last known follow-up (n = 55 395) or death (n = 19 655) using the United Network for Organ Sharing Database. The study period was divided into three 5-year eras: 2002-2006, 2007-2011, and 2012-2016. Kaplan-Meier survival analysis with log-rank test and Cox proportional hazards regression analysis were used to examine the allograft after transplant with marginal allografts, which were defined as 90th percentile Donor Risk Index allografts (calculated over the entire study period), donor after circulatory death allografts, national share allografts, old age (donors >70 years) allografts, fatty liver allografts, and 90th percentile Discard Risk Index allografts. Statistical analysis was performed from August to December 2019.MAIN OUTCOMES AND MEASURES Allograft failure after transplant as defined by the Org...

The use of the DSRI can help predict liver allograft discard. The DSRI can be used to effectively grade allografts and preferentially allocate marginal allografts to aggressive centers to maximize the donor yield and expedite allocation.

The field of liver transplantation has shifted considerably in the MELD era, including changing allocation, immunosuppression, and liver failure etiologies, as well as better supportive therapies. Our aim was to evaluate the predictive accuracy of the MELD score over time. The United Network for Organ Sharing provided de‐identified data on 120 156 patients listed for liver transplant from 2002‐2016. The ability of the MELD score to predict 90‐day mortality was evaluated by a concordance (C‐) statistic and corroborated with competing risk analysis. The MELD score's concordance with 90‐day mortality has downtrended from 0.80 in 2003 to 0.70 in 2015. While lab MELD scores at listing and transplant climbed in that interval, score at waitlist death remained steady near 35. Listing age increased from 50 to 54 years. HCV‐positive status at listing dropped from 33 to 17%. The concordance of MELD and mortality does not differ with age (>60 = 0.73, <60 = 0.74), but is lower in diseases that are increasing most rapidly—alcoholic liver disease and non‐alcoholic fatty liver disease—and higher in those that are declining, particularly in HCV‐positive patients (HCV positive = 0.77; negative = 0.73). While MELD still predicts mortality, its accuracy has decreased; changing etiology of disease may contribute.