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Keywords:

  • Liver transplant;
  • model for end-stage liver disease;
  • pediatric end-stage liver disease;
  • transplant outcomes

Abstract

  1. Top of page
  2. Abstract
  3. Waiting List
  4. Transplant, Deceased and Living Donation
  5. Outcomes
  6. Pediatric Transplant

ABSTRACT  The current liver allocation system, introduced in 2002, decreased the importance of waiting time for allocation priorities; the number of active wait-listed candidates and median waiting times were immediately reduced. However, the total number of adult wait-listed candidates has increased since 2002, and median waiting time has increased since 2006. Pretransplant mortality rates have been stable, but the number of candidates withdrawn from the list as being too sick to undergo transplant nearly doubled between 2009 and 2011. Deceased donation rates have remained stable, with an increasing proportion of expanded criteria donors. Living donation has decreased over the past 10 years. Transplant outcomes remain robust, with continuously improving graft survival rates for deceased donor, living donor, and donation after circulatory death livers. Numbers of new and prevalent pediatric candidates on the waiting list have decreased. Pediatric pretransplant mortality has decreased, most dramatically for candidates aged less than 1 year. The transplant rate has increased since 2002, and is highest in candidates aged less than 1 year. Graft survival continues to improve for pediatric recipients of deceased donor and living donor livers. Incidence of acute rejections increases with time after transplant. Posttransplant lymphoproliferative disorder remains an important concern in pediatric recipients.

I am just so grateful for this amazing gift I received.

Halley, liver recipient

In 2011, 5,805 adult liver transplants were performed in the United States (Figure 4.1). These included transplant of 5,351 organs from donation after brain death donors, 266 from donation after circulatory death (DCD) donors, and 188 from living donors. Organs were procured across the country and transplanted at 131 transplant programs (from deceased organ donation chapter, Figure 1.3). For the organ recipients, these life-saving operations are expected to provide an unadjusted 1-year survival of 88.2% (data not shown). These extraordinary results are achieved by collaboration among transplant surgeons, physicians, and other health care providers, as well as organ procurement and allocation personnel. Conversely, during 2011, 2,456 patients died while on the waiting list, and 482 patients were removed from the list because they were too sick to undergo transplant (Figure 1.5).

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Figure LI 4.1 . Total adult liver transplants  Patients receiving a transplant. Retransplants are counted.

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Figure LI 1.3 . Distribution of adult patients newly listed for a liver transplant  A newly listed patient is one who first joins the list during the given year, without having listed in a previous year. However, if a patient has previously been on the list, has been removed for a transplant, and has relisted since that transplant, the patient is considered a newly listed patient. Patients concurrently listed at multiple centers are counted only once. Malignancy as primary cause of disease includes, but is not limited to hepatocellular carcinoma (HCC); for some patients with HCC, another condition may have been cited as the primary cause of liver failure.

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Figure LI 1.5 . Liver transplant waiting list activity among adult patients  Patients with concurrent listings at more than one center are counted once, from the time of earliest listing to the time of latest removal. Patients listed, transplanted, and re-listed are counted more than once. Patients are not considered “on the list” on the day they are removed. Thus, patient counts on January 1 may be different from patient counts on December 31 of the prior year.

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Waiting List

  1. Top of page
  2. Abstract
  3. Waiting List
  4. Transplant, Deceased and Living Donation
  5. Outcomes
  6. Pediatric Transplant

The current allocation system, introduced in 2002, markedly decreased the importance of waiting time for liver allocation priorities. The number of active wait-listed liver transplant candidates was immediately reduced (Figure 1.1), as was the median waiting time (Figure 1.7). The proportion of wait-listed candidates who received an organ within 5 years of listing increased (Figure 1.9). Increasing proportions of candidates are older (Figure 1.2); the proportion of the largest age group, those aged 50 to 64 years, increased from 51.2% in 2001 to 63.7% in 2011. The proportion of male candidates increased gradually over time.

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Figure LI 1.1 . Adult patients waiting for a liver transplant  Patients waiting for a transplant. A “new patient” is one who first joins the list during the given year, without having listed in a previous year. However, if a patient has previously been on the list, has been removed for a transplant, and has relisted since that transplant, the patient is considered a “new patient.” Patients concurrently listed at multiple centers are counted only once. Those with concurrent listings and active at any program are considered active; those inactive at all programs at which they are listed are considered inactive.

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Figure LI 1.7 . Median months to liver transplant for wait-listed adult patients  Patients waiting for a transplant, with observations censored at December 31, 2011; Kaplan-Meier method used to estimate time to transplant. If an estimate is not plotted for a certain year, 50% of the cohort listed in that year had not been transplanted at the censoring date. Only the first transplant is counted.

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Figure LI 1.9 . Adult wait-listed patients who received a deceased donor liver transplant within five years  Patients with concurrent listings at more than one center are counted once, from the time of earliest listing to the time of latest removal. Patients listed, transplanted, and relisted are counted more than once.

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Figure LI 1.2 . Distribution of adult patients waiting for a liver transplant  Patients waiting for a transplant any time in the given year. Age determined on the earliest of listing date or December 31 of the given year. Concurrently listed patients are counted once. Malignancy as primary cause of disease includes, but is not limited to hepatocellular carcinoma (HCC); for some patients with HCC, another condition may have been cited as the primary cause of liver failure.

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A gradually worsening donor shortage trend is recognizable. Since 2002, the total number of wait-listed candidates gradually increased (Figure 1.1); most are listed as active. The median pre-transplant waiting time increased gradually but consistently since 2006 (Figure 1.7). The proportion of candidates with model for end-stage liver disease (MELD) scores greater than 15 also increased (Figures 1.2, 1.3). While pre-transplant mortality rates have been relatively stable since 2007 (Figure 1.10), the number of candidates withdrawn from the list because they were too sick to undergo transplant nearly doubled between 2009 (260) and 2011 (482; Figure 1.5). These data raise concern that wait-list mortality, which has decreased since the MELD-based allocation system was implemented, may increase again.

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Figure LI 1.10 . Pre-transplant mortality rates among adult patients wait-listed for a liver transplant  Patients waiting for a transplant. Mortality rates are computed as the number of deaths per 100 patient-years of waiting time in the given year. For rates shown by different characteristics, waiting time is calculated as the total waiting time in the year for patients in that group. Only deaths that occur prior to removal from the waiting list are counted. Age is calculated on the latest of listing date or January 1 of the given year. Other patient characteristics come from the OPTN Transplant Candidate Registration form.

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Geographic disparity in organ availability remains notable. The proportion of adults receiving deceased donor organs within 5 years of listing varied from less than 50% in some donation service areas (DSAs) to more than 80% in others (Figure 1.8). Similarly, mortality within 90 days of listing, regardless of transplant status, varied substantially by DSA; 90-day mortality varied more than 2-fold between DSAs with the lowest and highest mortality (Figure 1.12). As expected, the likelihood of undergoing transplant tended to be lower in DSAs with higher mortality. One possible approach to reducing wait-list mortality is to expand organ sharing among candidates at highest risk of death, as is currently done with status 1A and 1B patients. Based on analyses illustrated in Figure 1.11, showing that mortality for end-stage liver disease patients with the highest MELD scores (35 or higher) is nearly comparable to mortality for status 1A and 1B patients, a policy proposal for regional sharing of organs for those patients has recently been approved.

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Figure LI 1.8 . Percent of adult wait-listed patients, 2006, who received a deceased donor liver transplant within five years, by DSA  Patients with concurrent listings in a single DSA are counted once in that DSA, and those listed in multiple DSAs are counted separately per DSA.

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Figure LI 1.12 . Mortality within 90 days of listing for liver transplant, by DSA, 2009–2010  Percent of adult patients who die within 90 days of first listing. Patients with concurrent listings in a single DSA are counted once in that DSA, and those listed in multiple DSAs are counted separately per DSA. All deaths occuring within 90 days of listing are counted, including deaths occuring after transplant or removal from the wait list.

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Figure LI 1.11 . Mortality rates by medical urgency status, 2006–2011  Estimated hazard rate for death among patients waiting for liver transplant, stratified by medical urgency status at listing.

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Transplant, Deceased and Living Donation

  1. Top of page
  2. Abstract
  3. Waiting List
  4. Transplant, Deceased and Living Donation
  5. Outcomes
  6. Pediatric Transplant

In the past several years, deceased donor liver donation rates have remained stable (Figure 2.1). In response to the donor shortage, transplant surgeons continue their efforts to increase the donor pool.

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Figure LI 2.1 . Deceased donor liver donation rates  Numerator: Deceased donors age less than 65 whose liver was recovered for transplant. Denominator: US deaths per year, age less than 65. (Death data available at http://www.cdc.gov/nchs/products/nvsr.htm.)

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An increasing proportion of deceased donors are expanded criteria donors. The proportion of DCD organs has increased compared with the 1990s and remains at approximately 6% (Figures 2.7, 4.4). The proportion of organs donated after anoxic brain death increased more than 2-fold in the past decade, and the proportion of organs donated after death due to head trauma decreased (Figure 2.8).

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Figure LI 2.7 . Liver donors who are DCD  Deceased donors whose liver was recovered for transplant. DCD status is reported on the OPTN Deceased Donor Registration form.

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Figure LI 4.4 . Use of DCD livers among adult recipients, by recipient age  Percent of deceased donor transplants using a DCD donor.

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Figure LI 2.8 . Cause of death among deceased liver donors  Deceased donors whose liver was transplanted. CNS = central nervous system.

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Geographic inequality in deceased donor liver donation rates remains substantial (Figure 2.2). Variability between states with the highest and lowest donation rates is approximately 4-fold. This variability is accompanied by geographic differences in deceased donor transplant rates; by DSA, rates vary from 15.3 to 258.5 per 100 patient-years on the waiting list (Figure 4.6). Use of DCD donors varies widely by DSA, from 0% to 22.2% of transplants performed in 2009–2011 (Figure 4.5). Median MELD scores in adults receiving deceased donor livers ranged from 18.5 to 36.0; the national median MELD score is 27 (Figure 4.8).

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Figure LI 2.2 . Deceased donor liver donation rates (per 1,000 deaths), by state  Numerator: Deceased donors residing in the 50 states whose liver was recovered for transplant in the given year range. Denominator: US deaths by state during the given year range (death data available at http://www.cdc.gov/nchs/products/nvsr.htm). Rates are calculated within ranges of years for more stable estimates.

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Figure LI 4.6 . Deceased donor liver transplant rates per 100 patient years on the waiting list among adult candidates, by DSA, 2010–2011  Transplant rates by DSA of the listing center, limited to those on the waiting list in 2010 and 2011; deceased donor transplants only. Maximum time per listing is two years.

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Figure LI 4.5 . Percent of adult, deceased donor liver transplants that are DCD, by DSA, 2009–2011  Percent of deceased donor transplants using a DCD donor, by DSA of the transplanting center.

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Figure LI 4.8 . Median MELD score for adult deceased donor liver transplants, by DSA, 2011  Deceased donor liver transplants; DSA of transplant center location. Patients with status 1A, 1B and inactive status excluded, and allocation MELD score used.

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The number of donations from living donors reached a plateau at about 250, about half the number of a decade ago (Figure 3.1). The relatively low number of living donor transplants performed in the US is substantially less than the numbers performed in countries such as Japan and Korea, a disparity possibly reflecting more access to deceased donors in the US than in many parts of Asia. The gradual decrease in the number of living donors in the US over the past 10 years may be related to concerns about donor safety. Morbidity rates for living donors remain relatively low. Biliary complications in the first 6 weeks after donation are reported in less than 3% of living donors per year, except for 2007, when they were reported in 7.9% (Figure 3.8); most complications are reported as grade 1 or 2. Vascular complications in the first 6 weeks remain low, at less than 2% (Figure 3.9), and the frequency of reoperations in the first 6 weeks is low, at less than 4% (Figure 3.11).

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Figure LI 3.1 . Liver donations from living donors  Number of living donor donations; characteristics recorded on OPTN Living Donor Registration form.

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Figure LI 3.8 . Biliary complications among live liver donors  Complications reported on the OPTN Living Donor Registration forms. Type of complication is shown among all live donors, 2005–2011. Grade 1: Bilious JP drainage more than 10 days Grade 2: Interventional procedure (ERCP, PTC, percutaneous drainage, etc.) Grade 3: Surgical intervention

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Figure LI 3.9 . Vascular complications requiring intervention among live liver donors  Complications reported on the OPTN Living Donor Registration forms. Type of complication is shown among all live donors, 2005–2011.

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Figure LI 3.11 . Re-operation among live liver donors  Complications reported on the OPTN Living Donor Registration forms. Type of complication is shown among all live donors, 2005–2011.

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Unfortunately, two donor deaths were reported in 2010 (Figure 3.12), and these deaths clearly affected the views of the transplant community regarding living donation. The number of left lobe transplants increased slightly (Figure 3.5). Since left lobe and left lateral lobe segment donation are generally regarded as safer for the donor (less volume of tissue taken), the slight increase in the number of these procedures compared with right lobe donation may reflect ongoing safety concerns in the transplant community. In general, living donor rates are higher in geographic areas with higher median MELD scores; the transplant community may be avoiding living donation unless the candidate has a MELD score less than 30.

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Figure LI 3.12 . Living liver donor deaths  Living liver donors; domino donors excluded. Deaths as reported to the OPTN or Social Security Administration. “Donation related” deaths are included in the “Medical” category.

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Figure LI 3.5 . Living donor liver transplant graft type  Living donors by graft type for each year. Denominator: total number of living liver donors for each year.

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Several important trends among liver transplant recipients are apparent. First, increasing proportions of recipients are older. Over the past decade, the proportion of recipients aged 50 years or older increased from 58.5% to 77.1%, and the proportion aged 35 to 49 years halved, from 35.1% to 16.9% from 2002 to 2011 (counts shown in Figure 4.2). Absolute numbers are small, but the proportion of recipients aged 65 years or older has gradually increased, from 7.6% in 2002 to 12.8% in 2011. The proportions of recipients with obesity and diabetes have also increased (Table 4.9). Second, liver transplant rates in female candidates are increasingly recognized to be lower than rates in male counterparts. Several potential explanations may apply, and the gap may be narrowing in the past 2 to 3 years (Figure 4.3). Third, an upward trend remains for combined transplant. This is most notable for simultaneous liver-kidney transplant; these procedures increased more than 2-fold in the past decade (Figure 2.4). Simultaneous liver-kidney transplant remains a contentious topic, and the criteria for determining who is most appropriate for the procedure have not been established and adopted.

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Figure LI 4.2 . Adult liver transplants  Patients receiving a transplant. Retransplants are counted.

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Figure LI 4.9 . Characteristics of adult liver transplant recipients, 2001 & 2011  Patients receiving a transplant. Retransplants are counted.

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Figure LI 4.3 . Liver transplant rates in adult waiting list candidates  Patients waiting for a transplant. Transplant rates are computed as the number of transplants per 100 patient-years of waiting time in the given year. All waiting time per patient per listing is counted, and all listings that end in a transplant for the patient are considered transplant events.

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Figure LI 2.4 . Deceased donor livers transplanted with another organ  All patients receiving a deceased donor liver transplant. A transplant is considered multi-organ if any organ of a different type is transplanted at the same time. A multi-organ transplant may include more than two different organs in total; if so, each non-liver organ will be considered separately.

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Outcomes

  1. Top of page
  2. Abstract
  3. Waiting List
  4. Transplant, Deceased and Living Donation
  5. Outcomes
  6. Pediatric Transplant

Although liver transplant is being performed in increasingly challenging circumstances (more older recipients with more comorbidity undergoing transplant with high MELD scores and suboptimal donor organs), transplant outcomes in the US remain robust. In survival models with minimal adjustment (age, sex, race), the graft failure rate has continuously improved (Figure 6.2). Improvement in graft outcomes has occurred in deceased donor, living donor, and DCD transplants (Figure 6.1). As of June 30, 2011, 62,469 liver transplant recipients in the US were alive with a functioning graft (Figure 6.7).

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Figure LI 6.2 . Graft failure among adult liver transplant recipients, by diagnosis: deceased donor  Cox proportional hazards models reporting probability, adjusting for age, sex, and race.

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Figure LI 6.1 . Graft failure within the first 6 weeks after transplant among adult liver transplant recipients  All-cause graft failure is identified from multiple data sources, including the OPTN Transplant Recipient Registration, OPTN Transplant Recipient Follow-up, as well as death dates from the Social Security Administration.

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Figure LI 6.7 . Recipients alive & with a functioning liver transplant on June 30 of the year  Transplants before June 30 of the year that are still functioning. Patients are assumed alive with function unless a death or graft failure is recorded. A recipient can experience a graft failure and drop from the cohort, then be retransplanted and re-enter the cohort.

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Several factors affect graft survival after liver transplant, including recipient age, primary cause of disease, and status and MELD score at the time of transplant (Figures 6.4, 6.5). These factors have been well described and have relatively modest impact on absolute graft survival rates.

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Figure LI 6.4 . Graft survival among adult liver transplant recipients transplanted in 2006: deceased donors  Graft survival estimated using unadjusted Kaplan-Meier methods.

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Figure LI 6.5 . Graft survival among adult liver transplant recipients transplanted in 2003–2006: living donors  Graft survival estimatedl using unadjusted Kaplan-Meier methods. MELD >20 includes a small number of Status 1 or 1A patients.

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Successful liver transplant results are in part attributable to appropriate use of immunosuppression. Initial immunosuppression for most recipients is tacrolimus and mycophenolate mofetil (MMF), commonly in conjunction with steroids (Figure 7.1). Induction therapy is used infrequently (Figure 7.2). By 1 year after transplant, most patients are no longer taking steroids and are taking tacrolimus with or without MMF (Figure 7.3). With these immunosuppressive regimens, acute rejection occurs in less than 20% of recipients during the first year (Figure 6.8).

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Figure LI 7.1 . Initial immunosuppression regimen in adult liver transplant recipients, 2011  Patients transplanted in 2011 and discharged with a functioning graft. Top three baseline immunosuppression regimens are given, plus the “all others” group. Regimens are defined by use of calcineurin inhibitors (TAC = Tacrolimus, Cyclo = Cyclosporine), anti-metabolites (AZA = Azathioprine, MMF/MPA = Mycophenolate), and mTOR inhibitors (mTOR). Data within each regimen are reported separately by steroid use.

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Figure LI 7.2 . Induction agents used at time of liver transplant, adult recipients, 2011  Patients transplanted in 2011 and discharged with a functioning graft.

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Figure LI 7.3 . Immunosuppression regimen at one year in adult liver transplant recipients, 2010  Patients transplanted in 2010 and remaining alive with graft function one year post-transplant. Top three one-year immunosuppression regimens are given, plus the “all others” group. Regimens are defined by use of calcineurin inhibitors (TAC = Tacrolimus, Cyclo = Cyclosporine), anti-metabolites (AZA = Azathioprine, MMF/MPA = Mycophenolate), and mTOR inhibitors (mTOR). Data within each regimen are reported separately by steroid use.

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Figure LI 6.8 . Incidence of first acute rejection among adult patients receiving a liver transplant in 2005–2009  Acute rejection defined as a record of acute or hyperacute rejection, or a record of an antirejection drug being administered on either the Transplant Recipient Registration form or the Transplant Recipient Follow-up Form. Only the first rejection event is counted, and patients are followed for acute rejection only until graft failure, death, or loss to follow-up. Cumulative incidence, defined as the probability of graft failure at any time prior to the given time, is estimated using Kaplan-Meier methods.

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Pediatric Transplant

  1. Top of page
  2. Abstract
  3. Waiting List
  4. Transplant, Deceased and Living Donation
  5. Outcomes
  6. Pediatric Transplant

Waiting List

The number of new active pediatric candidates added to the liver transplant waiting list decreased from a peak of 969 in 2001 to 704 in 2011; few candidates were added as inactive (Figure 8.1). In a similar trend, the number of prevalent candidates on the waiting list has decreased. Since 2008, prevalent candidates with active status outnumber those with inactive status. The wait-list age distribution has changed little over the past decade; in 2011, 49.2% of listed candidates were aged 6 years or younger (Figure 8.2). The proportion of Hispanic wait-listed candidates increased from 14.8% in 1998 to 24.0% in 2011. The number of wait-listed candidates waiting for a retransplant decreased from 236 in 2001 to 76 in 2011 and represented 11.2% of wait-listed candidates (Figure 8.3). Among all wait-listed candidates in 2011, 8.2% of those aged 0 to 5 years were waiting for a re-transplant, as were 18.8% of those aged 6 to10 years and 15.3% of those aged 11 to 17 years. Pre-transplant mortality has steadily declined for candidates wait-listed for a liver-alone transplant, from 14.3 deaths per 100 wait-list years in 1998–1999 to 6.2 in 2010–2011; the most dramatic decline was in the group aged less than 1 year, where pre-transplant mortality was halved (Figure 8.7).

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Figure LI 8.1 . Pediatric patients waiting for a liver transplant  Patients waiting for a transplant. A “new patient” is one who first joins the list during the given year, without having listed in a previous year. However, if a patient has previously been on the list, has been removed for a transplant, and has relisted since that transplant, the patient is considered a “new patient”. Patients concurrently listed at multiple centers are counted only once. Those with concurrent listings and active at any program are considered active; those inactive at all programs at which they are listed are considered inactive.

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Figure LI 8.2 . Distribution of pediatric patients waiting for a liver transplant  Patients waiting for a transplant any time in the given year. Age determined on the lastest of listing date or January 1 of the given year. Concurrently listed patients are counted once.

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Figure LI 8.3 . Prior liver transplant in pediatric patients waiting for a liver transplant, by age  Prior transplant is obtained from the OPTN Transplant Candidate Registration form.

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Figure LI 8.7 . Pre-transplant mortality rates among pediatric patients wait-listed for a liver transplant, by age  Patients waiting for a transplant. Mortality rates are computed as the number of deaths per 100 patient-years of waiting time in the given 2-year interval. Waiting time is calculated as the total waiting time per age group in the interval. Only deaths that occur prior to removal from the waiting list are counted. Age is calculated on the latest of listing date or January 1 of the given period.

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Transplant

The number of deceased donor pediatric liver transplants peaked at 542 in 2008 and decreased to 477 in 2011. The number of living donor transplants decreased from a peak of 120 in 2000 to 59 in 2011 (Figure 8.8). The transplant rate has increased since 2002 to the current rate of 84.1 transplants per 100 patient-years on the waiting list (Figure 8.9). The transplant rate is highest for patients aged less than 1 year: 264 transplants per 100 patient-years on the waiting list. Over the past decade, the age, sex, and ethnic distributions of recipients have changed little (Figure 8.10). Cholestatic disease remains the leading cause of liver failure. More than 55% of patients who underwent transplant waited 60 days or fewer for transplant. Without taking into account exception scores provided by Organ Procurement and Transplantation Network (OPTN) policy, MELD/pediatric end-stage liver disease (PELD) scores at the time of transplant were 35 or higher for 14.7% of patients and less than 15 for 15.0%; the most common score range was 15 to 29. Most pediatric patients (63.6%) received a whole liver. The percentage of living donors declined from 19.4% during 1999–2001 to 10.6% during 2009–2011 (Figure 8.10). Use of DCD organs is rare in pediatric liver transplant, generally accounting for less than 1% (Figure 8.12).

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Figure LI 8.8 . Pediatric liver transplants, by donor type  Patients receiving a liver transplant.

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Figure LI 8.9 . Liver transplant rates in pediatric waiting list patients, by age  Patients waiting for transplant. Transplant rates are computed as the number of transplants per 100 patient-years of waiting time in the given year. Patients with concurrent listings at multiple centers are counted once.

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Figure LI 8.10 . Characteristics of pediatric liver transplant recipients, 1999–2001 & 2009–2011  Patients receiving a transplant. Retransplants are counted.

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Figure LI 8.12 . Use of DCD donors in pediatric liver transplant recipients  Patients receiving a DCD liver transplant.

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Immunosuppression and Outcomes

In 2011, tacrolimus was reported as part of the initial maintenance immunosuppressive medication regimen for 95.4% of pediatric liver transplant recipients and MMF for 40.1% (Figure 8.15). Steroid use was reported for 87.3% of recipients at the time of transplant, but for only 38.7% of 2010 recipients at 1 year after transplant. Mammalian target of rapamycin (mTOR) inhibitors were reported for 1.4% of recipients at the time of transplant and for 5.3% at 1 year after transplant. In 2011, 68.8% of liver transplants were performed with no induction immunosuppression (Figure 8.15). Graft survival has continued to improve over the past decade for recipients of deceased donor and living donor livers. Graft failure was 10.1% at 6 months for deceased donor transplants performed in 2010, 14.4% at 1 year for transplants performed in 2009, 19.6% at 3 years for transplants performed in 2008, 25.0% at 5 years for transplants performed in 2006, and 35.8% at 10 years for transplants performed in 2001 (Figure 8.16). Incidence of acute rejection increases with time after transplant. For liver transplants performed in 2005–2010, acute rejection occurred for 20.0% by 6 months after transplant, 30.6% by 12 months, and 36.8% by 24 months (Figure 8.19). Post-transplant lymphoproliferative disorder (PTLD) is an important concern in pediatric transplantation. The highest risk for PTLD and Epstein-Barr virus (EBV) infection occurs in EBV-negative recipients. Incidence of PTLD was 6.2% at 5 years after transplant in EBV-negative recipients and 4.0% in EBV-positive recipients (Figure 8.14).

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Figure LI 8.15 . Immunosuppression use in pediatric liver transplant recipients  One-year post-transplant data for mTOR inhibitors and steroids limited to patients alive with graft function one year post-transplant. One-year post-transplant data are not reported for 1998 transplant recipients, as follow-up data were very sparse.

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Figure LI 8.16 . Graft failure among pediatric liver transplant recipients: deceased donor  Cox proportional hazards model reporting probability, adjusting for age, sex, and race.

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Figure LI 8.19 . Incidence of first acute rejection among pediatric patients receiving a liver transplant in 2005–2010  Acute rejection defined as a record of acute or hyperacute rejection, or a record of an antirejection drug being administered on either the Transplant Recipient Registration form or the Transplant Recipient Follow-up Form. Only the first rejection event is counted, and patients are followed for acute rejection only until graft failure, death, or loss to follow-up. Cumulative incidence, defined as the probability of graft failure at any time prior to the given time, is estimated using Kaplan-Meier methods.

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Figure LI 8.14 . Incidence of PTLD among pediatric patients receiving a liver transplant, 1999–2009, by recipient Epstein-Barr virus (EBV) status at transplant  The cumulative incidence, defined as the probability of post-transplant lymphoproliferative disorder (PTLD) being diagnosed between the time of transplant and the given time, is estimated using Kaplan-Meier methods. PTLD is identified as either a reported complication or cause of death on the Transplant Recipient Follow-up forms or on the Post-transplant Malignancy form as polymorphic PTLD, monomorphic PTLD, or Hodgkin's Disease. Only the earliest date of PTLD diagnosis is considered, and patients are followed for PTLD until graft failure, death, or loss to follow-up. Patients are censored at graft failure because malignancies are not reliably reported after graft failure.

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Policy Updates

The OPTN Pediatric Transplantation and Liver and Intestinal Organ Transplantation Committees developed two proposals that were adopted by the OPTN Board of Directors in November 2011 and implemented on February 1, 2012: 1) to allow centers to seek permission to list all pediatric liver candidates with non-metastatic hepatoblastoma as status 1B, and 2) to eliminate the requirement that pediatric liver transplant candidates be in a hospital's intensive care unit to qualify as status 1A or 1B.