By Kathleen Struck, Senior Editor, MedPage Today
Published: May 20, 2013
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
The number of children dying before they could receive a transplant dramatically decreased from 262 to 110 as pediatric transplants increased from 2001 to 2010, stated Jennifer Workman, MD, of the University of Utah School of Medicine in Salt Lake City and colleagues, in Pediatrics.
The authors attributed major policy shifts for liver and kidney transplant protocols to the increase in transplants to children 17 and younger. Those organs compose the greatest percentage of solid-organ transplants in children, they noted.
Changes under the United Network for Organ Sharing (UNOS) allowed for increased transplantation from circulatory death donors while transplants from brain death donors decreased. UNOS is the private, non-profit organization that manages the nation’s organ transplant system under the federal government, according to it website.
In fact, recipients of pediatric donation after circulatory determination of death (DCDD) increased by 174% (50 to 137), while recipients of pediatric donation after neurologic determination of death (DNDD) decreased by 13% (2,992 to 2,614), Workman and colleagues stated.
“The increased use of DCDD kidneys and livers for transplantation into children may be one method to increase the number of pediatric transplants,” wrote Heung Bae Kim, MD, and Craig Lillehei, MD, of Harvard Medical School and Boston Children’s Hospital in an accompanying commentary.
However, “efforts to pursue living donation as the primary option for kidney transplantation in children” should not be ignored, Kim and Killehei wrote.
Other changes included policies affecting pediatric liver transplants, a liver disease end-stage scoring system, and, regional sharing of pediatric liver donors.
“Our analysis suggests that these liver allocation changes improved access to transplantation for children with liver failure and support earlier reports which investigated the effect of the model for end-stage liver disease/pediatric end-stage liver disease scoring systems on pediatric liver transplantation,” they wrote.
The authors obtained data from the Organ Procurement and Transplantation Network for U.S. organ recipients and donors from 2001 to 2010. Data were stratified by age, organ, and DCDD, and transplant wait-list removals due to death.
The criteria for donors for pediatric kidney transplants was expanded, giving pediatric recipients priority to kidney donors younger than 35. Pediatric kidney transplants increased an average 61 per year, the authors wrote.
“The kidney shortage remains an enormous problem for the transplant community, and allocation strategy changes to maximize donor kidney utilization are currently being assessed,” they wrote.
The authors noted that adult recipients far outnumber child recipients, while adult donors are more numerous than child donors.
The innovative techniques of split, live donor, and reduced liver grafts have increased the number of donations to transplants and decreased waiting times, the authors wrote, although data are conflicting about outcomes.
Interestingly, when a liver is split for size and first offered to a child, the other half typically goes to an adult recipient. However, if a liver is first offered to an adult, no regulations require that the adult be asked to split the liver with a child.
“To increase the availability of split livers from organs offered primarily to adults, adult transplant teams need to place greater importance on this option,” the authors said.
In the time period the authors assessed, 14,221 children received organ transplants from deceased donors. The transplant universe was broken down as:
Pediatric organ transplants increased from 1,170 to 1,475, peaking at 1,628 in 2009
Pediatric recipients increased 799 to 971
Pediatric donor organs used for transplantation decreased from 3,042 to 2,751
Pediatric donors decreased from 987 to 841
Pediatric transplant donors to adult recipients decreased 2,243 to 1,780
The majority of pediatric donor organs are still transplanted into adults, specially DCDD organs that are used almost exclusively for adult recipients.
“Although it is true that pediatric donation (both DCDD and DNDD) does not always directly benefit other children, improving the overall process of donation and increasing organ recovery allows for more pediatric transplants and fewer pediatric wait-list deaths,” the authors wrote.
The study had some limitations. The data were not indexed for population growth and some of the increased rates of donation and transplantation seen in the study years could be attributed to an increase in the overall population. Also, the database identifies donor organs allocated, not individual donors. Organs from a single donor can be used in up to eight individuals, the authors pointed out.
Finally, “during the study period, advances in the medical management of patients have evolved, allowing some of these children to improve and either delay or not require transplantation,” they said.