Advances and Answers in Pediatric Health
What started as an altruistic gesture to give a child a second chance at life, has turned into a movement. In 2017, an anonymous non-directed donor offered a portion of their liver to the University of Colorado Hospital, which they offered first to pediatric patients on the waiting list at Children’ s Colorado. Under the leadership of Elizabeth Pomfret, MD, and Michael Wachs, MD, of Children’ s Colorado, the pediatric LDLT program continued to grow with great outcomes for both recipients and donors. The total number of transplants for all donor types grew to 20 lifesaving transplants performed in 2021— the most since the program’ s inception in 1990. For the last several years, Children’ s Colorado has performed more than half of liver transplants from living donors— the majority of those from anonymous non-directed donors.
Traditionally, Pediatric End-Stage Liver Disease scores are used for prioritizing children on the waiting list for liver transplants, meaning their disease must progress and make them really sick before they can get a liver transplant. But LDLT allows recipients to get a liver transplant before they get to that stage of disease severity— leading to a quicker timeline to transplant, faster recoveries and better posttransplant outcomes.
“ Offering LDLTs allows recipients to bypass the uncertainty of being on a waiting list and receive a transplant before they get too sick,” says Dor Yoeli, MD,“ and the introduction of non-directed living donors expands the benefits to children on waiting lists who might not have a suitable directed live donor with a healthy liver and matching blood type.”
Interest in becoming a donor has also gone viral. Just a few years ago, a 4-year-old girl in Colorado received a liver transplant from an altruistic stranger after her parents posted on Facebook seeking a donor. Her story of receiving a donation from a complete stranger went viral, leading to five new non-directed liver donors.
BENEFITS OF LDLTS
LDLT is a win-win-win for patients, doctors and donors. It offers familiarity and a clearer view of the donor’ s liver quality and more control over the surgery timeline. For donors, donating to a child means less liver volume needs to be removed— as children only need a small part of the liver for it to regenerate to its full size. Waiting times at Children’ s Colorado are less than half the national average. Also, recipients of LDLTs are 42 % less likely to die and 44 % less likely to experience graft loss at one-year post-transplant( 4).
EXPANDING ACCESS
As Children’ s Colorado works to meet the demand for pediatric liver transplants in Colorado and regionally, Drs. Yoeli and Adams expect the program to expand nationally where patients experience more competition for liver transplants or don’ t have access to LDLT-capable centers.
“ There’ s also an added value of multiple listing,” says Dr. Adams,“ where patients are evaluated in Colorado and return home to wait for the first-available transplant— increasing their chances of receiving a transplant sooner.” Multiple listing means being listed at a patient’ s local primary liver center, but also listing at Children’ s Colorado to explore the possibility of living donation.
While other barriers exist, including far travel distances for treatment or a lack of awareness of the possibility to have a livedonor liver transplant, Children’ s Colorado and its multidisciplinary team of experts are well positioned to advance the care for some of the most complex cases in the U. S.
“ The benefits of LDLTs at high-volume centers are clear,” says Dr. Yoeli,“ but it’ s also worth exploring policies or programs that can help expand access to this lifesaving option and being thoughtful about addressing existing health disparities, rather than propagating them.” •
1. Perito ER, Roll G, Dodge JL, Rhee S, Roberts JP. Split Liver Transplantation and Pediatric Waitlist Mortality in the United States: Potential for Improvement. Transplantation. 2019 Mar; 103( 3): 552 – 557. doi: 10.1097 / TP. 0000000000002249. PMID: 29684000; PMCID: PMC6773658.
2. Yoeli D, Goss M, Galván NTN, Desai MS, Miloh TA, Rana A. Trends in pediatric liver transplant donors and deceased donor circumstance of death in the United States, 2002-2015. Pediatr Transplant. 2018 May; 22( 3): e13156. doi: 10.1111 / petr. 13156. Epub 2018 Jan 30. PMID: 29380468.
3. Rana A, Pallister Z, Halazun K, Cotton R, Guiteau J, Nalty CC, O’ Mahony CA, Goss JA. Pediatric Liver Transplant Center Volume and the Likelihood of Transplantation. Pediatrics. 2015 Jul; 136( 1): e99-e107. doi: 10.1542 / peds. 2014- 3016. Epub 2015 Jun 15. PMID: 26077479.
4. Barbetta A, Butler C, Barhouma S, Hogen R, Rocque B, Goldbeck C, Schilperoort H, Meeberg G, Shapiro J, Kwon YK, Kohli R, Emamaullee J. Living Donor Versus Deceased Donor Pediatric Liver Transplantation: A Systematic Review and Meta-analysis. Transplant Direct. 2021 Sep 20; 7( 10): e767. doi: 10.1097 / TXD. 0000000000001219. PMID: 34557584; PMCID: PMC8454909.
MEGAN ADAMS, MD
Associate Fellowship Director, Children’ s Hospital Colorado
Assistant professor, Department of Surgery, Division of Transplant Surgery, University of Colorado School of Medicine
DOR YOELI, MD
General surgery resident, Department of Surgery, Children’ s Hospital Colorado, University of Colorado School of Medicine
9