T】iANS】）LAN′rATlON l互止7（一，八b．β 1．286

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rccipicl】t・Saddcdtothewaitinglist．bctwccnl／1J95and12／ 31／97，fbt－rPOSSiblccvcntscou］d occur：1）thepaticn七was

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rcccived acadaveric organ，（living rcIatcd tTanSPiants ex－

cluded，reducedandsplitgl・a札sinch】ded），4）thepaticntdied bcfbre transplantation．Paticnts removed hm thelistbe－ CauSet，heyweretooilltoreceiveat，ranSplantwerccounted aspretransplantdeaths・Tablc4showstheestinlat・CSfbrthe PrObability ofthese fbur possible outcomesin the fiユ・St6

monthsa允erlistingfbrpatiehtsaddedtothclistbctwccn lJl／95and12／31J97．Both adult and pcdiatr・ic patients at

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donorhadlittleimpactonLheoddsof－E■ra托fhilurctoadu】t

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t・OSmaユIcrrecIP－ent・S・′rhiswouldencouragespliいivertrans－

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（Fig・2）・Itl：arlbcset＝一Ll－at；rC（luccdsixegraftsha〔lasigr）ill

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、′iv；11s、VU化；1lsりCX；1111ille〔l仙1t一；1川）l．sllOWrl），all（lsirllilar

】・（上Sllltぶ“′lユlて川1－SCr、′Cl】・tkcil11Se（Jltl・l－eC（Jmpl血1二yl）f一汁昭an；11－

yFi（一日【lげi、′C（1fl・（）nl（lご1l・；1；1C＝・l】e（ln、′CrS（ヱVe－・；lly郁＝・S，、化did こl仙±‖叩tLodul一－さCt：nnyl）【）SSjbl（上（ニC山cI・ヒIlbcLs．

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i11rllable9．

∫1－、VOmOdcIswcrc（lcvclopcd；the指】・Stdenncdapcdiatric

；l（lultllgCddonors…”1dreclplCnLs；inclu（1ingrcduccd；ln【lsr｝】iL

TAli－・じGt√11l・；1nSl】1；l再■Sf）el・n）1・∫－－C（ト〟川）・せ－1三三ノごi川）7，｝－ulnI）（汀S（｝1－ 、ち－l10le，1▼（三（luced，Split，；1－1dli、′inI三d－川01・Sl，ユ′）′Cこl】†i9さ）d－】！）！）7

’1－yl）e【汀Lrユ11Sl〕hnL

Yr W】101ビ 1le（九IC【、【l Split Li＼，（上 ‘1’oLill

26 45 三三8′i8

21 45 392′1

62 ′i6 4057

84 60 4158

193 196 14987

199′1 2669 】08

1995 ：177】 87

1996 ：j865 8rl

1997 3935 79

Total 14240 358

T＾I11』7．Numhcrsofwhole，rCd11CCd，6plitandlivi一昭 d（川01・Sl｝yこ1geOrl・eCipie】】t：199・ト1f）97

√rypヒD†transpli】nt

WllりIe li巳【1uced SpliL l」il∫仁 一110ta】 ′＼l；U

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35 ／17 づ88

】3 15 262

】3 】4 2ヒ；5

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1〔）3 ］9（； 】49とi7

く1 254

ト2 ：】0′1

ごト5 ］92

6－】0 223

11－1■7 375

181 12892

リー（山】】 】42′10

1：il

lO2

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35

2】

27

：：158

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（汀Cd．

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；1t LrarlSplant，11】e（1icこIIc…ユ〔ljti＝－（UNOS st一；1tllS）∫lt t一∫－ilIIS＝ Ⅰ〕1ilntパ0】discllCIlliatiT－1e，At∋0】－－；lt【‥l－，d…lり1・Cr（jrlt・i】liI・1Cl（三、り〕】， and ye；1rOf－hⅥnS】）】urlt；・1’11（＝）（1【1sり1’gr山t圭一illj－・eと1t－Ll甘Cl二！

n…・11一】1S，1ul】Ll二▲iγ【さ；1－一Sl）l）Stl二l・；lrl叩l；ll－l－Wl！】，l三（ld・lγ11i】－（J〔】（rl－；ト l）le5）．∧tal＝．11l－1〕tttil11（＝）（）il－t・S，Ll－e＝tlしtSt）l■併n化111ill】－－い、・l汀t－

signiLIcanl．1y】cssir］〕（】dint・ricrccil）iclltS（；’ト1’7y（l；11’S））－CCCivc（】

livers行omyountICrdoJlOrS（6p］7ycaltS）」nc（川Ll・aStl・hcodds

ofgraLtfhilurcateaclltlhncpnintlbrfLtrlullll・CCIP）Cnl・S、VCrC similar＼へThetherornoLthedonorwasyoungcroroldcr．

′ユー11CSamCnlultivari；1terCどrCSSion analysISIVaSrePCこ1t・（）d

butnowapp】ic（1toa】llpediatricandLLdultl・CCll〕ienLs，With ageexcll－Sionsnndinclusiveofsplitandreduccdgra几s・’r；ト

hle6shows the numbcrorrcJucc（1；1nd s】）1itorg乙1n t；r；1nS－ plants perLbrmed during thc pcriod orl，his analysIS，Elnd

TAliI用8．Oddsorg■Ⅰ・ilrtSulr7ivalc【）mp：11・e（1rorpe【li三1tric：111【1 glてIrtS

■ri111epUints

3MDl川正一■l’Ⅹ Dl）nOl・nEC（yr） IJumtズ【l 1Y－一Ⅰ－叩くtノ】’x 】lcclpill三e【J・r） 31rrpDSトー】、〉：

Oddsr乙Itio J）

0．65 く0．01

ユ．00 Reiニ

ユ．06 0．75

1．06 0、75

（，）（l（15r；高D Jl Olユdsl・こ1Lio J）

0－17 】786

18－t－ 8Ei2

0－j7 3225

18十 15300

n．G6

1．DO

O．G2

0．66

く0．01 0．G2 ＜0．01

ReI二 1．00 】le仁

・く0．01 0．84 0．29

・く〔】．01 0．86 0．33

VoJ．7（），〃0．9 ■rlもANSl）LAN■rA－11ION

1旭I－E9．Prol）OSedol・derofallocali‘，nhI・a】iv（汀丘l，Tlla

pediatl・icdoTlOr

1．Local Pcdiatricst．ahユSI

Adultst；ltuS1

2．Re由onal

Pcdint．ricst．atusI

Adultstat．us1

3．Local

Adultstatl】S2a

Pcdiatric stntus 2L

Adultstatl】S2b

Pediatri（：StatlユS3

AdultstatlユS3

4．RegionaI Adult status 2a

Pcdiatricstat．1】S2b

5．National PedjatricstatusI

AdultstムtusI

ndult status 2a

lldulL status ZL

Pediatricst．atus3 Adultstatus3

％％％ ％ ヽノ08 丁 J

Y＞hゝ再PSゞ

0 3 6 ， 1ユ1518 ユ1ヱ4 ヱ7 30 33 36

MonlhsPostTmnsplant

＿Li血gD…Or）lXXR亡du亡亡d 一一一軸曲几IY亡r ◆◆◆WI・bleLh′亡－

FIGUlⅦ2．TbeⅨaplan－Mkier3－year訂a几6urViva16are6bown hrpetliatricrecipieIltS Ofprima叩uVertranSplants6u・bdi－ videdbytypeoforganreceived・

donoras＜18yearS，andtheseconddc伽edapcdiatricdonor as＜18yearsandlessthanaspeciBedweightrange・・Three wclghtrangeswereinvestigated，＜40，＜45，and＜50kg・The sccondmodel＼YaS developedin rcsponsc to concerns that smalladultrecipientsmightbedisadvantagcdbythepro－ posedpediatricdefinitionof＜18ycarswi七houtwcightre－ stric七ions．

Neit．hermodeltakcsint，OaCCOuntthcdat，aPrCSCntedabovc whichshowsimproved paticntandgrd凡survivalsfbrc】一il－ drcnreccivinglivcrs什ompcdiatricaged donors・Fu］thcr， splitlivertransplantandoutcomeswerenotconsidered・

TablelO summarizes thc most relevent dat．afrom t．hq simulationscornparing thecurrenta1locatior）POlicytothe fburpropDSedpediatricdonordc丘nitions＝1）＜18years，2） ＜18yeal・Sandく40kg，3）＜18yearsand＜45kg，4）＜18 yearsand＜50．kg（Tablell）・

ThedatapresentedinTable12reprcsentstheaverageof cachmcasurefbr5years（1999－2003）andovcrfbursimula－ tionruns．Thedataaddress：1）thenun1berofpediatricand adt11tpatientstransplantcdbyage（pediatricrecipicntsdi－ vidcdOto5ycars，6－11ycars，1ト17ycEIrS）andbystatus，2） medianwaitingtime by status，and3）probabilityof■pre－ transplantdeathwithin6monthsoflisting・Thenumberof repeattransplants〉andpatientlifbyearsundcrthedi仔brent proposalsisnotshownbecausethcmodeldidnotaccountfbr expcctedimprovemcntsin pediatricgraftsurvivalshould pediatricsrccIPlentS reCCivelivers丘ornpcdiatricaged doT nOl－S．

Inalloftheproposedpolicies，Slightlymorepediatricpa－ tientsweretransplantedovcrthe5－yCilrPeriod・Thcincrease ovcrthecurreptpolicyrangedた■Om15lover5years（30per year）fbrthemostrestrictivepolicywithdonorsde重ncdas ＜18yearsand＜40kg，tO2970Ver5years（59peryear）the lcastrestrictive policy defininga pediatricdonoras＜18 years・Conscquently，eaChofthcpolicjesrcsultcdinacorTe－ spondingdecreaseinthenumberofadultpatientsrecciving transplants． Invcstiga七ingthechangcinthenumberoftransplantsby

ageandstatusshowedthatamongpcdiatricpatientsfbwcr werctransplantedinstatuslundertheproposedpo】icies・ Thisisbecausemorepediatricpaticntswcretransplar）tCdat lcssurgcntstatusesundertheproposedpolicies・Incontrast ；1l〕Outthesameorslightlyhighcrnulr）bersofadultpaticnts

weretransplantcdirlStatuSlbecausetherewerefbwcrpc－ diat一づcpatic11tSCOmPetingfbTOrga王】SWl扇】cinstatusl・This is rei】ectedin t，hcizICrCaSCd・numbers of chi）dren trans－

plantcd atstatus2B．Thiswasmostcvidentin thepo】icy deiiningpediatricdonors＜18yearswithoutweightrestric－ tion，Theincreasein pcdiatric stat11S2B patients trans－ plantedwas3040Ver5yearSCOmParedtocurTCntpOlicies． This bcncfit was diluted as the morc restrict二ivc pediatric donordefinitionsbyweightwere applied．In contrast，thc more stable pedia七ric paticnts畠t status3sl10WCd only a modestincrease，apPrOXimately4－10morechildrcnpcrycar． Inexaminingthcdatabysta七usfbradults，itisalsoilnPOr－ tanttonotcthatalloftheproposcdpo】icicsslightlyincrcased thenumberofad111tpaticntstransplantedatstat・uS2A．This ef詣ch・aJlgeda工nOJ】g18to78patieJlt50Ver5years・

Ofallpcdiatricdonorlivers，thepercentthatwentinto adultswas68．8％underthecul・rCntPOlicy．Undcrthelcast rcstrictiveproposedpolicythepeTCentageOfadultsstiu reT ceiv】ng Pediatric donors was59．2％，and ranged between 63－64％undertheothcrpediatricdonorproposalsdividcdby wcight．Thercwasa】soadecrcaseintheperccntageofadult livers thatweretranSplantedinto pcdiatricpatients．This wasmostprDnOunCed，3．9％，inthepolicydcfiningpediatric donors＜18years，withoutwcightrcstriction．Onlyanegli． gibleincrcaseinthe pcrcentage ofadultlivcrs thatwere transplantedintoadultswasde皿OnStrated．

Thepercentageoflocal，re釘Onal，andnationaltransplants wasessentia】】yuncha】1gedaswasthcavcrageand median distancetlleOrgantraVeled．Theperccntage oforgansthat b・aVeledgreatcrthanlOOOmi1esincrcascdfi・Oml．6tol．7％．

Deathspretransplantandposttransplantandtotaldeaths fbrtheproposcdpolicieswas changcswercnotcdwithallfburpoliciesproposed ascom－ ParCdtothccun・CntpOlicy．

WllCn thc probability ofpre transplant deathwithin6 montllSO‖istjng＼VaSallalyzed，t，herewercminimaldiflbr－ ences，nOne Ofwhich was st，atistically si卯if3cant，bctween