A national mandatory‐split liver policy: A report from the Italian experience

To implement split liver transplantation (SLT) a mandatory‐split policy has been adopted in Italy since August 2015: donors aged 18‐50 years at standard risk are offered for SLT, resulting in a left‐lateral segment (LLS) graft for children and an extended‐right graft (ERG) for adults. We aim to analyze the impact of the new mandatory‐split policy on liver transplantation (LT)‐waiting list and SLToutcomes, compared to old allocation policy. Between August 2015 and December 2016 out of 413 potentially “splittable” donors, 252 (61%) were proposed for SLT, of whom 53 (21%) donors were accepted for SLTwhereas 101 (40.1%) were excluded because of donor characteristics and 98 (38.9%) for absence of suitable pediatric recipients. The SLTrate augmented from 6% to 8.4%. Children undergoing SLTincreased from 49.3% to 65.8% (P= .009) and the pediatric LT‐waiting list time dropped (229 [10‐2121] vs 80 [12‐2503] days [P= .045]). The pediatric (4.5% vs 2.5% [P= .398]) and adult (9.7% to 5.2% [P< .001]) LT‐waiting list mortality reduced; SLToutcomes remained stable. Retransplantation (HR= 2.641, P= .035) and recipient weight >20 kg (HR= 5.113, P= .048) in LLS, and ischemic time >8 hours (HR= 2.475, P= .048) in ERGwere identified as predictors of graft failure. A national mandatory‐split policy maximizes the SLTdonor resources, whose selection criteria can be safely expanded, providing favorable impact on the pediatric LT‐waiting list and priority for adult sick LTcandidates. The introduction of a mandatory split policy in the Italian liver allocation system significantly increases the split liver transplantation rate, providing a favorable impact on the pediatric liver transplantation waiting list without harming the adult liver transplantation waiting list.