International Perspectives on Pediatric Split‐Liver Allocation: A Review of Policy Frameworks and the Swiss Experience

Pediatric liver allocation systems vary significantly across countries, reflecting different approaches to balancing urgency, equity, and the utilization of split-liver transplantation. This review examines international allocation frameworks and describes the evolution and impact of pediatric liver allocation policies in Switzerland. We conducted a comparative analysis of pediatric liver allocation systems in eight countries/regions (Switzerland, France, Eurotransplant, Italy, United States, United Kingdom, Canada, and Australia/New Zealand). For Switzerland, we analyzed waitlist data from the Swiss Organ Allocation System database for patients 0-16 years upon listing, comparing Era 1 (07.2007-06.2013) and Era 2 (07.2013-12.2023). International allocation systems demonstrate not only substantial variability in their approaches to pediatric priority and scoring systems, but also on split-liver mandates. Systems range from mandatory splitting policies (Switzerland, France, United Kingdom, Italy) to encouraged approaches (Eurotransplant, United States), to discretionary approaches (Canada, Australia/New Zealand). Studies in adult recipients show that splitting does not increase complication rates. In Switzerland, the implementation of mandatory splitting for donors < 50 years with recipients ≤ 25 kg significantly reduced median waitlist times for small children from 71 days (Era 1) to 29 days (Era 2). Pediatric liver allocation systems reflect diverse national priorities and institutional capacities. Mandatory split-liver policies can effectively reduce waitlist times for small children-without compromising the safety of adult recipients. The Swiss experience demonstrates that targeted regulatory changes, supported by advocacy and evidence, can meaningfully improve outcomes for pediatric recipients.