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 analyse the impact of the new mandatory-split policy on liver transplantation(LT)-waiting list and SLT outcomes, compared to old allocation policy. Between August 2015-December 2016 out of 413 potentially "splittable" donors, 252(61%) were proposed for SLT, of whom 53(21%) donors were accepted for SLT while 101(40.1%) were excluded because of donor characteristics and 98(38.9%) for absence of suitable paediatric recipients. The SLT rate augmented from 6% to 8.4%. Children undergoing SLT increased from 49.3% to 65.8%(p=0.009) and the paediatric LT-waiting list time dropped [229(10-2121) vs. 80(12-2503) days(p=0.045)]. The paediatric [4.5% vs. 2.5%(p=0.398)] and adult [9.7% to 5.2%(p<0.001)] LT-waiting list mortality reduced; SLT outcomes remained stable. Re-transplantation(HR=2.641, p=0.035) and recipient weight >20kg(HR=5.113, p=0.048) in LLS, and ischemic time >8hours(HR=2.475,p=0.048) in ERG were identified as predictors of graft failure. A national mandatory-split policy maximizes the SLT donor resources, whose selection criteria can be safely expanded, providing favourable impact on the paediatric LT-waiting list and priority for adult sick LT candidates. This article is protected by copyright. All rights reserved.