Application of Pediatric Donors in Split Liver Transplantation

Is There An Age Limit?

Wei Gao; Zhuolun Song; Nan Ma; Chong Dong; Xingchu Meng; Chao Sun; Hong Qin; Chao Han; Yang Yang; Fubo Zhang; Weiping Zheng; Zhongyang Shen


American Journal of Transplantation. 2020;20(3):817-824. 

In This Article

Abstract and Introduction


The experience of using pediatric donors in split liver transplant is exceedingly rare. We aim to investigate the outcomes of recipients receiving split pediatric grafts. Sixteen pediatric recipients receiving split liver grafts from 8 pediatric donors < 7 years were enrolled. The donor and recipient characteristics, perioperative course, postoperative complications, and graft and recipient survival rates were evaluated. The mean follow-up time was 8.0 ± 2.3 months. The graft and recipient survival rates were 100%. The liver function remained in the normal range at the end of the follow-up time in all recipients. No life-threatening complications were seen in these recipients, and the only surgery-related complication was portal vein stenosis in 1 recipient. Cytomegalovirus infection was the most common complication (62.5%). The transaminase level was significant higher in extended right lobe recipients in the early postoperative days, but the difference vanished at the end of first week; postoperative complications and graft and recipient survival rates did not differ between left and right graft recipients. Notably, the youngest split donor graft (2.7 years old) was associated with ideal recipient outcomes. Split liver transplant using well-selected pediatric donors is a promising strategy to expand pediatric donor source in well-matched recipients.


Split liver transplant (SLT) is a worldwide well-accepted strategy to expand donor liver pool. This method generates 2 liver grafts from 1 donor; 2 recipients can be rescued at the same time.[1] In well-selected donor grafts, the use of SLT has shown to increase the number of liver grafts by 15%;[2] comparable recipient outcome has been achieved among SLT, living donor liver transplant, and whole liver transplant in both adult and pediatric patients.[3–5]

Although the application of SLT is optimistic, problems still exist. Which kind of liver grafts are suitable for split remains an open question. One recent study revealed that only 3.8% of the liver grafts that met the criteria for split were actually used in SLT in the United States; the number of "split-able" liver grafts was greater than pediatric waitlist deaths.[6] This study is consistent with a previous report showing young pediatric patients had the greatest mortality rate while on the waitlist.[7] The lack of age- and size-matched grafts and the underused "split-able" liver grafts are 2 major reasons result for this high mortality rate in pediatric patients. Expanding the criteria for SLT through split-liver grafts from pediatric donors might be considered a potential measure to expand the donor pool for pediatric patients. Currently, most of the discussions regarding SLT criteria focus on the upper age limit of the donors.[8] There is a scarcity of clinical studies investigating the use of pediatric donors in SLT, and the lower age limit for "split-able" liver grafts is still unknown. In this study, we reported 16 pediatric liver transplants with 8 split-liver grafts from pediatric donors younger than 7 years, and analyzed the postoperative recipient and graft outcomes. We aim to increase the donor availability for pediatric patients by evaluating the possibility of using young pediatric donor grafts in SLT.