Survival Benefit of Split-Liver Transplantation for Pediatric and Adult Candidates

Abstract

Patient and graft survival are similar following whole-liver transplantations (WLTs) versus split-liver transplantations (SLTs) among pediatric and adult recipients, yet SLTs are rarely used. We sought to determine the survival benefit associated with accepting a splittable graft offer for SLT versus declining and waiting for a subsequent offer using 2010 to 2018 Scientific Registry of Transplant Recipients (SRTR) data on 928 pediatric and 1814 adult liver transplantation candidates who were ever offered a splittable graft. We compared eventual mortality, regardless of subsequent transplants, between those patients who accepted versus declined a split liver offer with adjustments for Pediatric End-Stage Liver Disease/Model for End-Stage Liver Disease (MELD) scores, diagnosis, and weight among pediatric candidates and matching for MELD score, height, and offer among adult candidates. Among pediatric candidates ≤7 kg, split liver offer acceptance versus decline was associated with a 63% reduction in mortality (adjusted hazard ratio [aHR], _0.17 0.37_0.80 [P = 0.01]; 93.1% versus 84.0% 1-year survival after decision). Within 1 year of decline for those ≤7 kg, 6.4% died and 31.1% received a WLT. Among pediatric candidates >7 kg, there was no significant difference associated with acceptance of a split liver offer (aHR, _0.63 1.07_1.82 [P = 0.81]; 91.7% versus 94.4% 1-year survival after decision). Within 1 year of decline for those >7 kg, 1.8% died and 45.8% received a WLT. Among adult candidates, split liver offer acceptance was associated with a 43% reduction in mortality (aHR, _0.39 0.57_0.83 [P = 0.005]; 92.2% versus 84.4% 1-year survival after decision). Within 1 year of decline for adult candidates, 7.9% died and 39.3% received a WLT. Accepting split liver offers for SLT could significantly improve survival for small children and adults on the waiting list.

FIG. 1.

Pediatric and adult study population. Pediatric cases and controls not matched on MELD/PELD or height. Adult cases and controls matched on (1) the same graft offer, (2) ±2 MELD points, and (3) ±15 cm in height.

FIG. 2.

Distribution of weight (kg) and height (cm) of pediatric liver transplant candidates who accepted (triangle) and declined (circle) split liver offers. Symbols are shown with transparency to illustrate increased density in areas of overlap. Each shape represents a candidate who had the opportunity to accept a split liver offer. Axes are on a log scale so that differences at low values can be observed.

FIG. 3.

Distribution of height (cm) and weight (kg) of adult female and male liver transplantation candidates who accepted (triangle) and declined (circle) split liver offers. Symbols are shown with transparency to illustrate areas of increased density.

FIG. 4.

Pediatric patient survival following the decision to accept versus decline a split liver offer stratified by candidate weight. Pediatric candidates followed from the date of decision until death or administrative censorship on April 30, 2018, irrespective of subsequent deceased donor SLT or WLT or removal from the waiting list. Pediatric candidates were censored for living donor liver transplantation.

FIG. 5.

Adult patient survival following the decision to accept versus decline a split liver offer. Adult candidates matched on the split liver offer, MELD score at offer, and height. Adult candidates followed from the date of decision until death or administrative censorship on April 30, 2018, irrespective of subsequent deceased donor SLT or WLT, living donor liver transplantation, or removal from the waiting list.