Variability in Acceptance of Organ
Offers by Pediatric Transplant Centers
and Its Impact on Wait-List Mortality
Kathleen M. Loomes,
Robert H. Squires,
and David Goldberg
Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medi-
cal Center, Pittsburgh, PA;
Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia,
Philadelphia, PA; and
Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
Recent data have suggested that pediatric patients wait-listed for a liver transplantation frequently have liver offers
declined. However, factors associated with liver offer decisions and center-level variability in practice patterns have not
been explored. We evaluated United Network for Organ Sharing data on all match runs from May 1, 2007 to December
31, 2015 in which the liver was offered to 1 pediatric patient; the transplant recipient was ranked in the ﬁrst 40 positions
for the organ offer; and the donor was brain-dead and <50 years of age. We used multilevel mixed effects models to evalu-
ate factors associated with organ offer acceptance, among-center variability, and the association between center-level accep-
tance and wait-list mortality. There were 4088 unique pediatric patients during the study period, comprising 27,094 match
runs. Initial Model for End-Stage Liver Disease or Pediatric End-Stage Liver Disease score, history of exception points,
recipient region, rank on match run, and geographic share type were all associated with probability of offer acceptance.
There was signiﬁcant among-center variation (P < 0.001) in adjusted liver offer acceptance rates, accounting for donor,
recipient, and match-related factors (adjusted acceptance rates: median, 8.9%; range, 5.1%-14.6%). Center-level acceptance
rates were associated with wait-list mortality, with a >10% increase in the risk of wait-list mortality for every 1% decrease
in a center’s adjusted liver offer acceptance rate (odds ratio, 1.10; 95% conﬁdence interval, 1.01-1.19). In conclusion, there
is signiﬁcant among-center variability in liver offer acceptance rates for pediatric patients that is not explained by donor
and recipient factors. A center’s liver acceptance behavior signiﬁcantly impacts whether a pediatric patient will be trans-
planted or die on the waiting list.
Liver Transplantation 24 803–809 2018 AASLD.
Received December 11, 2017; accepted February 27, 2018.
SEE EDITORIAL ON PAGE 729
Pediatric patients wait-listed for a liver transplantation
(LT) in the United States are prioritized based on
their Model for End-Stage Liver Disease (MELD) or
Pediatric End-Stage Liver Disease (PELD) score,
depending on the patient’s age.
When a liver from
a deceased donor becomes available, a list of all patients
eligible for such organs is created by the United
Network for Organ Sharing (UNOS), which is depen-
dent on donor factors and recipient compatibility. The
UNOS rank list is based on a patient’s MELD/PELD
score and his/her geographic location relative to the
potential donor. When an offer for a deceased donor
liver is made, the transplant physician must determine
whether to accept or decline the offer for a given
patient, often without discussion with the patient and/
or his/her next-of-kin due to time constraints and/or
complexities of the organ offer process.
Although there are several characteristics that deﬁne
the “quality” of a donor liver, a principal objective fac-
tor of donor organ quality is the donor’s age.
an offer is made, transplant physicians must weigh not
only the “quality” of the donor liver, but also must bal-
ance this against the following factors:
1. The clinical stability of the potential recipient.
2. The likelihood the patient will receive another
offer of similar quality in the near future.
Abbreviations: ALF, acute liver failure; BSA, body surface area; CI,
conﬁdence interval; DSA, donor service area; IQR, interquartile
range; IRD, increased risk donor; LDLT, living donor liver trans-
plantation; LT, liver transplantation; MELD, Model for End-
Stage Liver Disease; OR, odds ratio; PELD, Pediatric End-Stage
Liver Disease; PHS, Public Health Services; UNOS, United Net-
work for Organ Sharing.
MITCHELL ET AL.