CLINICAL AND TRANSLATIONAL RESEARCH Impact of Change in the United Kingdom Pediatric Donor Organ Allocation Policy for Intestinal Transplantation Mara Giovanelli, 1 Girish L. Gupte, 1 Patrick McKiernan, 1 Phil Pocock, 2 Susan V. Beath, 1 Carla Lloyd, 1 Khalid Sharif, 1 David A. Mayer, 1 and Darius F. Mirza 1,3 Background. Graft availability remains a problem in pediatric intestinal transplantation (IT), with most children waiting being less than 10 kg weight. In November 2004, wait-listed children in the United Kingdom were prioritized nationally to receive pediatric donor organs to improve donor availability for IT. We aimed to evaluate the impact of this change on the recipient population. Methods. Data regarding pediatric donor organ availability and allocation were accessed from the National Transplant database. Recipient demographics and outcomes were recorded from the Liver Unit database. Between 2001 and 2006, there were 228 pediatric donors in the United Kingdom (nonheart-beating donors were excluded), of which 39 livers were allocated to emergency super-urgent liver candidates. A total of six isolated intestine and 21 liver-intestine transplants (15 reduced size, six full grafts) were performed in the same period. Results. Since January 2001, there has been a progressive reduction in overall pediatric organ donation. Increasing awareness about IT has resulted in a significant increase in number of small bowel organs being offered (71.8% vs. 19.5%), although this has been associated with an increase in referrals for transplantation. Despite an increase in number of IT being performed (2.6 vs. 7.7 mean transplants per year), waiting list mortality still remains high in smaller children (10 kg weight). No mortality was observed in larger children and in candidates for isolated IT. Conclusions. The new prioritization of the national pediatric donor allocation favoring IT has resulted in an increased number of procedures, without an impact on waiting list mortality for small children. Keywords: Donor allocation, Pediatric, Intestinal transplantation, Waiting list mortality. (Transplantation 2009;87: 1695–1699) I ntestine transplantation (IT) has become an effective therapy for children with irreversible intestinal failure dependent on total parenteral nutrition (TPN) and is indicated in those with life-threatening complications of TPN (1, 2). Most of these chil- dren are unable to wait prolonged periods for scarce size- matched grafts to become available. United Network for Organ Sharing data reveal that waiting list mortality for IT candidates exceeds that for all other organ candidates (3). Graft availability represents a major problem especially in the pediatric popula- tion, given the critical shortage of size-matched donor organs. Infants and small children in need of combined liver and intes- tine transplant have prolonged waiting times and have a high risk (up to 50%) of dying before transplantation (3–5). Two strategies have been proposed to alleviate the excess mortality in this group: assignment of higher allocation scores to patients on waiting list for combined liver-intestine grafts thereby prioritizing donor organs to this group (6), and implan- tation of reduced-size grafts from adults or larger children (7, 8). In the United Kingdom, a decision to prioritize pediatric donors nationally to pediatric liver and bowel recipients ahead of elec- tive pediatric liver recipients was made in 2004 to help increase graft availability for this most vulnerable group of recipients. This report analyzed the impact of the change in national priori- tization and allocation on the recipient population only at the United Kingdom pediatric intestinal transplant unit. We also studied the impact of this change on children listed at our center for elective liver transplantation. Finally, we looked at the effect on a selected group of extremely vulnerable children—those weighing less than 10 kg with historically the highest waiting list mortality in excess of 50%. MATERIALS AND METHODS Since November 2004, there has been a change in the prioritization of national pediatric donor organ allocation in This work was supported by the European Society of Organ Transplantation (M.G.). The authors declare no conflict of interest. The work was presented at the Xth International Small Bowel Transplanta- tion Symposium held in Los Angeles, CA on September 6 – 8, 2007. 1 Liver Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom. 2 Department of Statistics, UK Transplant, Bristol, United Kingdom. 3 Address correspondence to: Darius F. Mirza, M.S., F.R.C.S., Nuffield House, 3rd floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom. E-mail: darius.mirza@uhb.nhs.uk Received 5 December 2008. Revision requested 7 January 2009. Accepted 23 February 2009. Copyright © 2009 by Lippincott Williams & Wilkins ISSN 0041-1337/09/8711-1695 DOI: 10.1097/TP.0b013e3181a5e9f8 Transplantation • Volume 87, Number 11, June 15, 2009 www.transplantjournal.com | 1695