Tailoring allocation policies and improving access to paediatric liver transplantation over a 16-year period

background & aims: mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. we analysed the Italian pLT WL to evaluate the intention -to -treat (ITT) success rate and to identify factors influencing success. methods: all children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002-2007]: centre -based allocation; Era 2 [2008-2014]: national allocation; era 3 [2015-2018]: national allocation+mandatory-split policy). results: a total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7-27]) were listed for pLT. median WL time was 2 days (IQR 1-5) for Status 1 and 44 days (IQR 15-120) for non -status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). predictive factors for receiving LT included status 1 (hazard ratio [HR] 1.66, p = 0.001), status 1B (HR 1.96, p = 0.016), status 2A (HR 2.15, p = 0.024) and each 1 -point increase in PELD/MELD score. children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re -transplantation (HR 5.83, p <0.001), status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), status 2A (HR 9.12, p <0.001), recipient weight <6 kg (HR 4.53, p <0.001) and low -volume activity (HR 4.38, p = 0.001). conclusions: In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory -split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. (c) 2023 european association for the study of the liver.