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Chinnakotla S. Eliminating wait list mortality in pediatric liver transplantation–split grafts are a critical component. Presented at: American Transplant Congress; June 4-8, 2022; Boston.
Disclosures:
Chinnakotla report no relevant financial disclosures.
Expanding access to split liver transplants and adopting a “split first” policy on donor livers will significantly reduce mortality on the pediatric waitlist, noted a presenter at the American Transplant Congress 2022.
“This is not data that we want to see: There is significant mortality on the pediatric waitlist in the United States,” Srinath Chinnakotla, MD, professor of surgery, surgical director of liver transplantation and executive medical director of pediatric abdominal transplantation at the University of Minnesota, told attendees. “In 2020, we did 500 pediatric liver transplants: 17 children died on the waitlist and 16 were too sick and removed, so most likely, they also didn’t make it. We are looking at 33 children every year in U.S. dying on the waitlist.”
Chinnakotla noted that although Dr. Rudolf Pichlmayr successfully performed a split liver transplantation for a child in 1988, the field has not significantly advanced since then. In fact, according to a report from the Scientific Registry of Transplant Recipients, there has been no change in the number of split liver transplants performed in the U.S. from 2005 to 2020.
Citing the 2019 study from Perito and colleagues in Transplantation, Chinnakotla noted that over a 5-year period, more than 4,000 donor livers met the criteria for splitting. However, even after excluding 170 for high-risk donors and about 1,000 for a non-favorable recipient, 96% of the remaining livers were primarily allocated as whole liver recipients into adults, with only 4% used for split transplantation.
“We don’t split enough,” Chinnakotla said. “Even if 96% of those patients that accepted those whole livers were actually listed as accepting a segment graft, much of the time the decision not to split is made by the individual surgeon that is accepting the liver.”
So, why are surgeons not splitting?
“This is probably multifactorial,” Chinnakotla said. “One reason is that the allocation system doesn’t favor it, in the sense that if you’re willing to split a liver, you have to put the right tri-segment back into the allocation system. If you take a little bit of risk for anatomy, you don’t get the graft. The second is that there is a misconception that splitting the liver causes risks to the adult, which is not true. The third is logistics. I think that sometimes we don’t play well in the sandbox — we don’t agree on which vessels will be shared, which surgeon is going to split, and there is not much cooperation among centers, which is unfortunate.”
Compared with the U.S., Europe has a very different allocation, he noted. In the United Kingdom, for all donors are aged less than 40 years “there is a deliberate intention to split,” Chinnakotla said, while in Italy, all donors aged less than 50 years are “mandatory to split and they are offered to the pediatric patient first.” Similarly, in France, all donors aged less than 30 years must be split and are allocated to a pediatric recipient with an intent to split.
“That allocation system has resulted in an increase in splits to almost 22%,” he said. “Although the U.K. doesn’t do as many pediatric livers as United States, they do approximately 70 to 80 pediatric livers a year, and their waitlist mortality is like zero.”
Chinnakotla encouraged surgeons to move from voluntary to intention-to-split donor livers to improve pediatric access.
“As surgeons, we need to take charge — we need to push for a ‘split first’ policy like they do in Italy and France,” he said. “If we do that, I’m almost certain that we can stop the death on pediatric waitlist. Europe has been successful, and we can do it as well.”
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