Approximately 10% of children on the U.S. liver transplant waiting list die before they receive a transplant, in large part because of the lack of size-matched organs. Techniques such as technical variant liver transplantation (TVLT) exist for creating liver grafts, but a lack of awareness and expertise has limited its use. A recent study suggests that pediatric waitlist mortality is significantly reduced when high-volume transplant centers utilize TVLT.
Mercedes Martinez, MD, Medical Director of the Intestinal Transplant Program at the Center for Liver Disease and Abdominal Organ Transplantation at NewYork-Presbyterian and Columbia, shares her perspective on how to safely increase the use of TVLT and reduce waitlist mortality for children in need of liver transplantation.
Increasing awareness of TVLT can help reduce mortality for kids on the U.S. liver transplant waiting list.
Why TVLT Expertise and Access Are Key
Although TVLT has been around for decades, there have long been misconceptions that technical variance creates a lower-quality graft, making some physicians and parents unwilling to consider its use. Indeed, a physician should not perform TVLT without the appropriate training and experience because that could lead to poor outcomes. However, if a surgeon with the appropriate skills and expertise leads the surgery, then technical variance provides nearly the same quality as whole organs. In fact, when these grafts come from living donors, they can be of even higher quality.
Physicians at NewYork-Presbyterian have been pioneering the use of TVLT in both living and deceased donors since 1998. As experts in this approach, we can minimize the time that our patients spend on the liver transplant waiting list and provide transplant opportunities for children as young as a few months old. In some cases, we have been able to transplant two children from one donor liver, while other times, a small part of the liver graft will go to a child and an adult uses the remainder. The use of TVLT has allowed us to optimize organs and minimize deaths of children on the waiting list.
The use of TVLT has allowed us to optimize organs and minimize deaths of children on the waiting list.
— Dr. Mercedes Martinez
A recent study published in Transplantation supports our experience at NewYork-Presbyterian. The study examined the impact of TVLT on waiting mortality, specifically looking at each transplant center’s procedural volume. The researchers found a 23% reduction in waitlist mortality among high-volume centers that performed TVLT the most. I believe that transplant centers that consistently do more than 20 pediatric liver transplants per year are the ones that will have the experience to safely perform TVLTs.
Transparency is critical to ensuring that TVLT is available to more children on the liver transplant waiting list. Families should be told the outcomes for both TVLT and whole grafts as well as the waiting list mortality at their center. The regulatory bodies should mandate the disclosure of this information as part of the informed consent process. While it would mean more paperwork, I think it would go a long way to ensuring that only transplant centers with surgical expertise perform TVLT, ensuring good outcomes.
Insurers also have a role in expanding access to TVLT, since coverage often dictates where patients can receive care. They should advocate for children to receive care at a center of excellence, where they would have the best outcomes. The overall cost of care is also likely to be lower because patients will spend less time on the transplant waiting list.
TVLT can be a critical tool to getting children off the transplant waiting list and back to leading healthy lives — as long as it is performed by physicians with the right training and skills. The medical community needs to work together to improve awareness and education so that more of these pediatric patients get access to this lifesaving procedure.
