Waitlist outcomes after acuity circle-based distribution in pediatric liver transplantation.

Pediatric liver transplant (LT) waitlist mortality remains unacceptably high. In 2020, the Organ Procurement and Transplantation Network (OPTN) implemented acuity circle (AC)-based liver distribution and national pediatric prioritization for pediatric donor livers. Using OPTN data, waitlist outcomes for pediatric LT candidates listed between February 4, 2016 and February 3, 2024, were studied by age group and era relative to AC implementation. There were 5,605 waitlist registrations and 3,778 liver transplants. At 1 year, cumulative incidence of transplant was 77.8% pre-AC vs 79.9% post-AC; cumulative incidence of mortality was 5.4% pre-AC vs 5.9% post-AC. Median allocation Model for End-Stage Liver Disease/Pediatric Model for End-Stage Liver Disease score at LT significantly decreased across all age groups post-AC (p<0.001). Candidates age 12-17 years experienced higher cumulative incidence of transplant (65.6% pre-AC vs 79.5% post-AC at 1 year), decreased median time to transplant (66 days pre-AC vs 37 days post-AC, p<0.001), and increased proportion of pediatric donor livers (37.9% pre-AC vs 66.2% post-AC, p<0.001). AC group was associated with increased likelihood of transplant for those age 12-17 years and increased likelihood of waitlist mortality for those age 1-5 years. LT candidates age 12-17 years derived the most benefit from AC-based liver distribution.