Inequality in Pediatric Liver Transplantation

OBJECTIVES: Access disparities persist across centers performing pediatric liver transplant (LT). Quantifying the magnitude and drivers of these inequities is essential for improving organ use and preventing pseudo-access, which is when a waitlisted child does not receive an expected transplant. We evaluated center-level variation in donor use, offer acceptance practices, and transplant rates nationally and quantified access inequality. METHODS: Cross-sectional analyses of all active US pediatric LT centers using the Scientific Registry of Transplant Recipients Program-Specific Reports from January 1, 2023 to December 31, 2024 was performed. Center activity, including volumes and organ offer acceptance ratios, was assessed, and centers were stratified into quartiles (Q) with the highest quartile (Q4) having the highest volume. Metrics included acceptance intensity, transplant rate ratios (TRRs), and phenotype groups based on their combinations. Inequality in access was quantified using Gini coefficients. RESULTS: Across 59 centers, median volume ranged from 0.50 (Q1) to 34.00 (Q4; P < .001), and new listings ranged from 6 to 53 (P < .001). TRRs were lower in Q1 vs Q4 centers (0.04 vs 0.96; P = .001), and 1-year mortality was highest in Q1 and lowest in Q4 (hazard ratio, 1.13 vs 0.85; P = .03). Phenotyping revealed 4 center types, with "aggressive utilizers" demonstrating the highest acceptance intensity (1.25) and TRR (1.84; both P < .001). Gini coefficients demonstrated inequality, with Q4 performing 61.1% of volume while listing 52.1% children. CONCLUSIONS: Inequality metrics show that pediatric LT activity is concentrated in a small subset of centers. Many programs demonstrate pseudo-access, with low acceptance intensity and low transplant rates despite active listing. Addressing these disparities will require structural and process-level reforms.