Building Equity Through Experience: Insights From 1560 Single-Center Pediatric Liver Transplants in a Developing Country.

Over the past 34 years, a single transplant team in São Paulo, Brazil, has performed 1560 pediatric liver transplants (PLT)-including 1352 LDLT, 179 DDT, and 29 domino procedures using donors with maple syrup urine disease-achieving outstanding long-term outcomes. In our most recent cohort of 500 PLT (2018-2024), 1- and 5-year patient survival rates were 96.7% and 94.8%, respectively. From 2015 to 2024, our team performed 35.1% of all PLT in Brazil and 45.5% of those in children under 5 years of age, with 98.1% of the latter using LDLT. This milestone highlights not only clinical achievement but also the persistent structural challenges facing PLT in low- and middle-income countries. We outline some key barriers to sustainable and equitable PLT development in Brazil, including underfunding, geographic disparities, lack of outcome transparency, bureaucratic delays, and gaps in transition to adult care. A set of guiding principles is proposed to support national progress and inform similar efforts elsewhere. Our center's experience demonstrates that excellence in PLT is achievable in resource-constrained settings, but long-term success depends on institutional commitment, strategic investment, and national coordination to ensure equitable access for all children.