Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics Stanford University Stanford California USA Division of Gastroenterology, Hepatology & NutritionDepartment of Medicine University of California San Francisco California USA Division of Pediatric HepatologyDepartment of Pediatrics Icahn School of Medicine at Mount Sinai New York New York USA Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of PediatricsUniversity of CaliforniaSan Francisco California USA.
Liver Transpl. 2022 Sep;28(9):1520-1528. doi: 10.1002/lt.26437. Epub 2022 Apr 19.
Equity is a core principle in both pediatrics and solid organ transplantation. Health inequities, specifically across race, socioeconomic position, or geography, reflect a moral failure. Ethical principles of prudential life span, maximin principle, and fair innings argue for allocation priority to children related to the number of life years gained, equal access to transplant, and equal opportunity for ideal posttransplant outcomes. Iterative policy changes have aimed to narrow these disparities to achieve pediatric transplant equity. These policy changes have focused on modifying pediatric priority for organ allocation to eliminate mortality on the pediatric transplant waiting list. Yet disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes. Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children. Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes. Children living farther from a transplant center have higher waitlist mortality. Herein we review the current knowledge of these racial and ethnic, socioeconomic, and geographic disparities for these children. To achieve equity, stakeholder engagement is required at all levels from providers and health delivery systems, learning networks, institutions, and society. Future initiatives must be swift, bold, and effective with the tripartite mission to inform policy changes, improve health care delivery, and optimize resource allocation to provide equitable transplant access, waitlist survival, and posttransplant outcomes for all children.
公平是儿科学和实体器官移植学的核心原则。健康不公平，特别是在种族、社会经济地位或地理位置方面，反映了道德的失败。审慎的寿命原则、最大最小原则和公平竞争原则等伦理原则主张，根据获得的生命年数、平等获得移植的机会以及理想移植后结果的平等机会，将儿童列为优先分配对象。迭代政策变化旨在缩小这些差距，以实现儿科移植公平。这些政策变化侧重于修改儿科器官分配的优先级，以消除儿科移植等待名单上的死亡率。然而，在所有时间点，儿科肝移植仍然存在差异：从获得转诊进行移植的机会、活体供者移植的可能性、使用例外叙述、等待名单死亡率以及移植后结果的不公平。与白人儿童相比，黑人儿童获得例外评分的可能性较低、等待名单死亡率较高、不太可能成为活体供者移植的接受者，并且移植后结果较差。居住在社会经济最贫困社区的儿童移植后结果较差。居住在离移植中心较远的儿童等待名单死亡率较高。在此，我们回顾了这些儿童的种族、族裔、社会经济和地理差异的现有知识。为了实现公平，从提供者和医疗服务系统、学习网络、机构和社会各个层面都需要利益相关者的参与。未来的举措必须迅速、大胆且有效，以实现三重使命，即告知政策变化、改善医疗服务提供和优化资源分配，为所有儿童提供公平的移植机会、等待名单生存和移植后结果。
