Challenging the Traditional Paradigm of Supply and Demand in Pediatric Liver Transplantation Through Nondirected Living Donation: A Case Series

Living Donor Liver Transplantation for Young Biliary Atresia Recipients Is Associated With Improved Outcomes in the Modern Era

INTRODUCTION

Biliary atresia (BA) is the most common indication for liver transplantation (LT) in children. We aimed to identify risk factors associated with survival in young patients with BA in the modern era.

METHODS

We performed a retrospective analysis of BA patients aged < 2 years who received their first isolated LT with available data from the United Network for Organ Sharing database (01/2013-12/2022). Factors included in the multivariable Cox regression were graft type, race/ethnicity, insurance status, laboratory pediatric end-stage liver disease (PELD) score, history of portal vein thrombosis, and intensive care unit (ICU) status.

RESULTS

1226 BA LT recipients aged < 2 years were included, of whom 501 (40.9%) received deceased donor whole grafts (DDWG), 425 (34.7%) received deceased donor technical variants (DDTV), and 300 (24.5%) received living donor LT (LDLT). LDLT recipients were more likely to be white (p = 0.008) and have private insurance (p < 0.001). Multivariable analysis demonstrated that ICU status (hazard ratio [HR] = 3.23, 95% confidence interval [95% CI]: 1.72-6.08, p < 0.001) and DDTV graft vs. LDLT (HR = 3.03, 95% CI: 1.14-8.04, p = 0.03) were associated with an increased risk of patient mortality. Factors associated with an increased risk of graft loss included ICU status (HR = 1.89, 95% CI: 1.19-3.00, p = 0.007) and both DDWG (HR = 3.37, 95% CI: 1.65-6.87, p = 0.001) and DDTV (HR = 3.47, 95% CI: 1.69-7.14, p = 0.001) grafts vs. LDLT.

CONCLUSION

LDLT is associated with improved survival in patients with BA aged < 2 years; however, socioeconomic differences exist between LDLT and non-LDLT recipients. Efforts to promote early equitable referral to centers offering LDLT are essential for improving outcomes in young children with BA.

Can non-directed living liver donation help improve access to grafts and correct socioeconomic disparities in pediatric liver transplantation?

BACKGROUND

Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D-LLD LT. ND-LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D-LLD versus ND-LLD LT.

METHODS

The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed ≥1 ND-LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non-directed) and recipient insurance.

RESULTS

Of 299 pediatric LDLT, 46 (15%) were from ND-LLD performed at 18 transplant centers. Fifty-nine percent of ND-LLD recipients had public insurance in comparison to 40% of D-LLD recipients (p = .02). Public insurance was associated with greater odds of ND-LLD in comparison to D-LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23-4.58, p = .01).

CONCLUSIONS

ND-LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D-LLD and ND-LLD transplants are needed.

Marginal parental donors for pediatric living donor liver transplantation

PURPOSE OF REVIEW

Living donor liver transplantation (LT) has been increasingly recognized as an effective treatment modality with excellent patient survival. Indications for LT have evolved not only for cholestatic liver disease, but also metabolic liver diseases. Living donor selection, particularly for pediatric inherited disease, is essential to prevent morbidity, both in the donor and recipient.

RECENT FINDINGS

Based on 30 years of experience in pediatric living donor LT in Japan, we could identify marginal parental living donors who have potential risks following LT, including heterozygous mothers with ornithine transcarbamylase deficiency, heterozygous protein C deficiency, heterozygous hypercholesterolemia, heterozygous protoporphyria, asymptomatic parental donors with paucity of intrahepatic bile duct, and human leukocyte antigen-homozygous parental donors.

SUMMARY

Although these situations seem rare due to infrequency of the condition, careful living donor evaluation is required to optimize the outcomes for pediatric recipients. In the setting of an appropriate selection of a living donor, we should avoid any additional hazards, given that the procedure itself has risks for a healthy individual.

Living Donor Liver Transplant Center Volume Influences Waiting List Survival Among Children Listed for Liver Transplantation

BACKGROUND

Pediatric living donor liver transplantation (LDLT) remains infrequently performed in the United States and localized to a few centers. This study aimed to compare pediatric waiting list and posttransplant outcomes by LDLT center volume.

METHODS

The Scientific Registry of Transplant Recipients/Organ Procurement and Transplantation Network database was retrospectively reviewed for all pediatric (age <18 y) liver transplant candidates listed between January 1, 2009, and December 31, 2019. The average annual number of LDLT, deceased donor partial liver transplant (DDPLT), and overall (ie, LDLT + DDPLT + whole liver transplants) pediatric liver transplants performed by each transplant center during the study period was calculated.

RESULTS

Of 88 transplant centers, only 44 (50%) performed at least 1 pediatric LDLT during the study period. LDLT, DDPLT, and overall transplant center volume were all positively correlated. LDLT center volume was protective against waiting list dropout after adjusting for confounding variables (adjusted hazard ratio, 0.92; 95% confidence interval, 0.86-0.97; P = 0.004), whereas DDPLT and overall center volume were not (P > 0.05); however, DDPLT center volume was significantly protective against both recipient death and graft loss, whereas overall volume was only protective against graft loss and LDLT volume was not protective for either.

CONCLUSIONS

High-volume pediatric LDLT center can improve waiting list survival, whereas DDPLT and overall volume are associated with posttransplant survival. Expertise in all types of pediatric liver transplant options is important to optimize outcomes.

Practices and Perceptions of Living Donor Liver Transplantation, Nondirected Donation, and Liver Paired Exchange: A National Survey

Living donor liver transplantation (LDLT) remains underutilized in the United States. Barriers to LDLT and acceptance of nondirected living liver donation (ND-LLD) and liver paired exchange (LPE) are unclear. The medical and surgical directors of 99 unique transplantation programs (56 LDLT programs and 43 non-LDLT programs) were surveyed to gain insight into perceptions and practices of LDLT and types of donors utilized. The response rate was 84%. Most LDLT programs (65%) reported performing ND-LLD, though opinions regarding allocation and the need for additional evaluation of these donors were mixed. Only a minority of LDLT programs reported performing LPE (12%), but most programs (78%) would be open to cross-institutional LPE barring logistical barriers. There were significant differences between LDLT and non-LDLT programs with regard to perceived barriers to LDLT, with LDLT programs reporting mainly donor and recipient factors and non-LDLT programs reporting institutional factors (P < 0.001). Understanding perceptions and practices of LDLT, ND-LLD, and LPE is important to aid in the growth of LDLT.