Impact of allocation priority for children awaiting liver transplantation in Korea: a pediatric liver allocation simulated model analysis.

Background In Korea, pediatric deceased donor livers are not prioritized for pediatric candidates, resulting in inequities in organ allocation. Current split liver transplantation (SLT) criteria, which are limited to children younger than 15 years and weighing less than 30 kg, fail to reflect the actual body size of many pediatric candidates.

Methods We retrospectively reviewed the Korean Network for Organ Sharing database for all deceased donor liver transplantations (DDLT) performed between 2000 and 2020. Donor and recipient characteristics, allocation trends, and survival outcomes were analyzed. Simulation analyses were conducted to assess the feasibility of prioritizing pediatric candidates for pediatric deceased donors.

Results Among 5,252 DDLT cases, 328 (6.2%) were pediatric recipients, of whom only 121 (36.9%) received grafts from pediatric deceased donors. Pediatric donor livers were allocated to adult recipients more than twice as often as to children. Survival analysis demonstrated superior outcomes in pediatric recipients compared with adults (5-year survival, 86.0% vs. 68.9%; P<0.001), regardless of donor age. No significant survival difference was observed between SLT and whole liver transplantation among pediatric recipients. Simulation modeling indicated that prioritizing pediatric candidates for pediatric and splittable adult deceased donors could increase pediatric DDLT by more than 300 cases without reducing graft availability for adult recipients.

Conclusions Pediatric recipients demonstrate superior posttransplant outcomes but face limited access to pediatric deceased donor grafts under current Korean allocation policies. Revision of allocation principles-prioritizing pediatric candidates for pediatric deceased donors and expanding SLT criteria based on body weight-could substantially reduce reliance on living donor liver transplantation in pediatric patients.