Living-Donor Liver Transplant Lowers Cost for Children with Biliary Atresia

For years, Children’s Hospital Colorado’s Pediatric Liver Transplant Program has led the field in performing living-donor liver transplants. During these transplants, a healthy adult donates a small portion of their liver to a child in need. Living donors can direct their liver to a specific child (directed donation), or can donate their liver to go to anyone in need (nondirected). Children’s Colorado currently has the highest volume of both directed and nondirected pediatric liver transplants in the country.

The team invests heavily in this area of work because deceased organs small enough for children are difficult to acquire, resulting in long waitlists. Living donation shortens the time a child spends on the waitlist and is particularly valuable for infants in need of liver transplants, as they are the age-group most likely to die on the liver transplant waitlist. In addition to shortening waitlist times, living-donor liver transplants are associated with improved patient and graft survival.

Because not all pediatric hospitals offer living donation, families often choose to multilist their children at both their home hospital and a center that offers living donation like Children’s Colorado. Unfortunately, when families multilist, insurance providers don’t always pay for the additional costs that can come with that, such as a second evaluation and travel costs.

Amy Feldman, MD PhD, Medical Director of the Children’s Hospital Colorado Liver Transplant Program, knew she needed to provide a different type of data — cost data — to change payers’ minds about covering living-donor liver transplant and multilisting.

“What information is lacking or what information can we provide that might move the needle for payers?” Dr. Feldman recalls asking. “Payers often speak in terms of dollars and hospital resources. So, we thought if we could provide payers with data that showed them living-donor liver transplant was less expensive and used fewer costly resources than deceased-donor liver transplant, perhaps we could encourage them to support a living-donor option for every child across the country.”

Designing the study and getting results

Dr. Feldman began by compiling hospital cost and resource utilization data for children less than 2 years of age transplanted for biliary atresia — the most common indication for pediatric liver transplant — to show the positive financial impact living-donor transplants can have.

To get a complete picture of each patient’s journey, including financial information, Dr. Feldman worked with experts to link together two national databases: the Pediatric Health Information System database and the Scientific Registry of Transplant Recipients.

“This is really the wave of the future,” Dr. Feldman says. “We want to be able to combine big data sets so that we can tell full patient stories.”

To answer their question, the team compared children who underwent living-donor liver transplant to those who underwent deceased-donor liver transplant during three key periods: pretransplant hospitalizations, transplant hospitalization and any hospitalizations occurring in the first year following transplant.

The financial benefits of living-donor transplant

“The big finding was that during transplant hospitalization, living-donor transplant was $45,000 less expensive and less dialysis was needed for children undergoing living-donor transplant,” Dr. Feldman says.

Additionally, the team found that during the pretransplant period, hospitalizations for children who ultimately underwent living-donor liver transplant cost, on average, $20,000 less. Additionally, living-donor patients needed less total parenteral nutrition.

These differences are likely due to the fact that living-donor liver transplant allows children to get their transplant sooner, when they are often healthier and can tolerate major surgery better. That means less time on intravenous nutrition, less need for dialysis and, ultimately, better outcomes.

“We now know that in addition to shorter waitlist times and improved clinical outcomes pre- and post-transplant, living donation also results in lower costs and resource utilization” Dr. Feldman adds. “The data is clear that every child should have access to living-donor liver transplant.”

Turning research into advocacy

About 1 in 10 infants on the pediatric liver waitlist die before they get the surgery they need. According to Dr. Feldman, this statistic is one we must work as a community to change.

Studies like this aim to move the needle but represent just a piece of the work the Children’s Colorado team is doing to make a difference.

“Ensuring that every child across the country has access to living donation is one part of the solution. At the same time, we must also work to improve national allocation policies for deceased organs.” Dr. Feldman says. She and the Children’s Colorado team are working with partners across the country to mandate organ splitting so that both a child and an adult can be saved by one liver graft. The team is also working to standardize and increase exceptions for children with a high risk of waitlist mortality.

In addition to partners across the U.S., Dr. Feldman and the team partner closely with nearby University of Colorado. This serves as a national model for cross-institutional collaboration in transplantation. Beyond working together to provide exceptional clinical care for donors and recipients, the University of Colorado has committed to offering nondirected living-donor livers to children on the Children’s Hospital Colorado transplant waitlist. This partnership has expanded access to lifesaving transplantation and enabled Children’s Colorado to perform the highest volume of both directed and nondirected pediatric living-donor liver transplants in the nation.

These different bodies of work have one common goal: ensuring no child dies on the liver transplant waitlist. “Policy changes regarding deceased donation are absolutely needed,” Dr. Feldman says, “but until we have those policy changes in place, living donation is the way to get children a transplant as quickly as possible."