COMMENTARY

Reduced Demand, Increased Supply: Innovations Are Brightening Liver Transplantation Outcomes

The Liver Meeting 2017: American Association for the Study of Liver Diseases (AASLD)

William F. Balistreri, MD

Disclosures

December 04, 2017

In This Article

Split Liver Transplantation to Decrease Pediatric Deaths

Children on waiting lists for liver transplantation have lower survival rates than adults. Approximately 45% of children who die on the waiting list never receive an organ offer.[8] A reduction in pediatric waiting-list mortality could, in part, be addressed with greater use of split transplantation.

In the United Kingdom, defaulting to split liver transplantation with suitable deceased donor grafts has virtually eliminated pediatric waiting-list mortality. From 2011 through 2014, 18% of pediatric liver transplants involved a split liver, and there were no deaths on the waiting list.[9] In the United States, less than 2% of donor livers are split, while 1 in 10 infants die on the waiting list. Only 29% of children receive a partial or split graft, and only 3.4% of "splittable" adult liver grafts are actually split.[8]

Perito and colleagues[9] have shown that we can do better. Using UNOS data, livers from all transplanted, deceased donors potentially available for split liver transplantation were identified using stringent criteria, including donor age 18-40 years, body mass index <30 kg/m2, minimal vasopressor usage, serum sodium <155 meq/L, aspartate aminotransferase/alanine aminotransferase levels <100 IU/L, bilirubin level <3 mg/dL, <7 days hospitalized, steatosis ≤10%, and no bloodstream infection. They concluded that of 35,461 livers transplanted in the United States between 2010 and 2015, 7% were potentially usable for split liver transplantation. Of these, 95% were transplanted whole; 50% went to recipients deemed possibly high risk for split liver transplantation. This left 1116 potential livers for split transplantation; 78% of their primary recipients were listed as willing to accept a segmental liver.

During the same period, 261 children died on the waiting list. Of these, 56% were under 2 years of age, 26% were 2-12 years old, and 18% were 13-18 years old; 36% died at centers that reported doing no or few pediatric split liver transplantations. The investigators emphasized that there were enough "splittable" livers available to treat all of the 261 children who died on the transplant waiting list during that period because in each of the 11 UNOS regions, the number of potentially splittable organs was greater than the number of children who died on the waiting lists.

There will be constraints of cost, skill, and logistics in promoting split liver transplantation, but the inconvenience should not be an excuse when patients' lives are at stake.

There are several barriers to increasing the number of split liver transplants, including changes to allocation policies and practice as well as reducing the reluctance of some transplant surgeons to undertake graft splitting, concern for patient outcomes, technical and logistical complexity, and the fact that many transplant centers have limited experience. However, incentives to increase liver splitting would save children from dying while waiting for an organ. It is clear that the increased use of split liver transplantation could expand organ access and decrease pediatric waiting-list mortality—without decreasing liver transplantation access for adults. There will be constraints of cost, skill, and logistics in promoting split liver transplantation, but the inconvenience should not be an excuse when patients' lives are at stake.[10]

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