Purpose: Concerns about early recurrence and death limit access to liver transplantation (LT) for children with advanced primary liver malignancy (PLM). However, long term survival after pediatric LT for PLM is excellent, which implies it may be reasonable to increase access to transplantation, even in the face of higher rates of early recurrence and death. Here, we seek to understand the impact of early mortality on the survival benefit of LT for children with PLM.

Methods: We analyzed patients waitlisted for LT in the UNOS STAR files (1990-2024) and simulated long-term survival of pediatric LT recipients using age-specific mortality rates derived drom all adult and pediatric transplant recipients. We used propensity score matching to generate a matched control group and estimated the absolute survival benefit of transplanted children, compared to controls. We simulated how increasing the number of patients with PLM who die within 5 years after LT affects the magnitude of the survival benefit.

Results: We estimate that LT for PLM is associated with a 35.4 year survival benefit compared to 9.9 years for adults. In simulated pediatric PLM populations where 40%, 60%, and 80% of recipients die within 5 years, the survival benefit was 19.5 (95%CI 18.0-22.9), 10.1 (9.15-10.9), and 1.7 (1.19-2.5) years respectively (Figure 1).

Conclusions: Our simulations predict that even children with a very high rate of early mortality experience a survival benefit from LT for PLM. Our findings support efforts aimed at increasing access to LT for children with PLM.