The Impact of Increased Allocation Priority for Children Awaiting Liver Transplant

Abstract

Objective: The aim of the study was to investigate the impact of prioritizing infants, children, adolescents, and the sickest adults (Status 1) for deceased donor livers. We compared outcomes under two “SharePeds” allocation schema, which prioritize children and Status 1 adults for national sharing and enhanced access to pediatric donors or all donors younger than 35 years, to outcomes under the allocation plan approved by the Organ Procurement and Transplant Network in December 2017 (Organ Procurement and Transplantation Network [OPTN] 12-2017). Methods: The 2017 Liver Simulated Allocation Model and Scientific Registry of Transplant Recipients data on all US liver transplant candidates and liver offers 7/2013 to 6/2016 were used to predict waitlist deaths, transplants, and post-transplant deaths under the OPTN 12-2017 and SharePeds schema. Results: Prioritizing national sharing of pediatric donor livers with children (SharePeds 1) would decrease waitlist deaths for infants (<2 years, P = 0.0003) and children (2–11 years, P = 0.001), with no significant change for adults (P = 0.13). Prioritizing national sharing of all younger than 35-year-old deceased donor livers with children and Status 1A adults (SharePeds 2) would decrease waitlist deaths for infants, children, and all Status 1A/B patients (P < 0.0001 for each). SharePeds 1 and 2 would increase the number of liver transplants done in infants, children, and adolescents compared to the OPTN-2017 schema (P < 0.00005 for all age groups). Both SharePeds schema would increase the percentage of pediatric livers transplanted into pediatric recipients. Conclusions: Waitlist deaths could be significantly decreased, and liver transplants increased, for children and the sickest adults, by prioritizing children for pediatric livers and with broader national sharing of deceased donor livers.

A Review of the Current State of Liver Transplantation Disparities

“…In children, prioritizing the allocation of pediatric grafts to pediatric recipients on the national level prior to adults on the regional level would likely result in decreased mortality in pediatric liver candidates, particularly in the age group <12 years old who have the most difficult time finding appropriately sized grafts. ( 68,70,82 ) One study simulating the effect of the newly implemented acuity circles allocation scheme found that the new UNOS policy will likely decrease waitlist deaths in pediatric recipients and result in more pediatric grafts being allocated to pediatric recipients rather than adult recipients. ( 69 ) In the adult literature, age matching and age mapping are 2 of the more well‐studied equity principles, both of which match organ recipients to donors of a similar age with the theory that younger (and thus better) organs should be prioritized to younger recipients.…”

Situación actual del trasplante hepático pediátrico por hepatopatías crónicas en Chile: Inequidades asociadas a la priorización por sistema MELD/PELD

“…No hubo diferencias significativas en la mediana de puntaje MELD/ PELD al alistamiento en cada grupo (p = 0,136) (Tabla 1). La mediana de puntaje MELD/PELD al alistamiento fue menor en pacientes con etiología colestásica comparado con otras etiologías (17 [9][10][11][12][13][14][15][16][17][18][19][20][21] versus 21 [20-30], respectivamente; p = 0,003). Debido a falta de registro del puntaje MELD/PELD al retiro de LE (por trasplante o fallecimiento), no se consideró esta variable en el análisis.…”

“…De hecho, aquellos pacientes que fallecieron lo hicieron precozmente, ya que la mitad de los pacientes pediátricos fallecen antes de cumplir 3 meses en LE. Por ende, la implementación del sistema MELD/PELD en Chile no ha disminuido desde la era previa a MELD/PELD (25%-29%), lo cual aún está por encima de cifras latinoamericanas de mortalidad pediátrica en LE (Argentina 18% y Brasil 15%) o norteamericanas (10%) 7,13,14 . Sin duda, esto genera una gran cantidad de años de vida potencialmente perdidos en nuestros candidatos.…”

Barriers to ideal outcomes after pediatric liver transplantation

“…The feasibility of a decrease in pediatric wait list deaths, concurrent with an overall increase in LTs performed, was recently demonstrated in a liver simulated allocation model analysis prioritizing pediatric plus the sickest (Status 1) adult patients for deceased donor livers utilizing data from the SRTR. 21…”

“…Despite 5%‐10% yearly increases in organ donation and concurrent increments in total transplants performed annually, death or “removal for too sick to transplant” rates range from 7% to 12% on the pediatric LT wait list, while the number of pediatric LTs performed yearly has remained relatively fixed. The feasibility of a decrease in pediatric wait list deaths, concurrent with an overall increase in LTs performed, was recently demonstrated in a liver simulated allocation model analysis prioritizing pediatric plus the sickest (Status 1) adult patients for deceased donor livers utilizing data from the SRTR …”