Benchmarking paediatric living donor liver transplantation for establishing standards to expand access and save lives: retrospective global cohort study.

BACKGROUND

Paediatric liver transplantation increasingly incorporates technical variant grafts including living donor liver transplantation (LDLT) to address donor shortages. However, the technical complexity of LDLT and regional outcome variations remain challenging. In settings with such variation and ongoing debate, standardized benchmarks may guide decision-making for broader implementation. This study establishes benchmark cut-off values for paediatric LDLT outcomes to provide a validated framework for quality assessment and safe programme expansion.

METHODS

An international analysis was conducted of paediatric patients who underwent LDLT at 19 centres between 2019 and 2023. Benchmark cut-off values were derived from 'ideal' patients at seven high-volume institutions, representing the best achievable results under optimal conditions. Surgical complications were graded using the Clavien-Madadi classification, compared against the standard Clavien-Dindo system for accuracy.

RESULTS

In all, 2665 patients were included, of which 1988 counted as ideal patients. The median recipient age was 10 (interquartile range (i.q.r.) 6-26) months with median weight of 8.0 (i.q.r. 6.6-11.9) kg. Biliary atresia was the most common diagnosis (68.8%), and most recipients (90.9%) received a left lateral segment graft. The 75th percentile of median centre values were used to define the following benchmark cut-off values: hepatic artery thrombosis ≤ 5%, bile leak ≤ 12%, biliary anastomotic stricture ≤ 6%, and 1-year graft loss or mortality ≤ 6%. Higher centre volume was associated with more selective patient inclusion and fewer major (particularly biliary) complications. An inverse correlation between case volume and failure-to-rescue rate highlighted the critical role of multidisciplinary perioperative management. The Clavien-Madadi classification proved superior to the Clavien-Dindo system, which overclassified grade III complications.

CONCLUSIONS

This study provides a framework to guide safe programme expansion, improve surgical quality, and reduce waitlist mortality.