We read with interest the excellent analysis by Rhee et al. which supports their contention, and an emerging perception, that pediatric end-stage liver disease (PELD) scores based on chronic liver failure may be less applicable for acute liver failure. Death of a 2-year-old awaiting liver retransplantation for acute graft failure at our center supports these conclusions further and motivates our suggestions herein, based on additional focused analyses. After primary live-donor segmental liver transplantation (LTx) for unresectable hepatoblastoma, our patient experienced rapidly evolving LTx failure due to septic shock complicating posttransplantation chemotherapy. Throughout the 55-day wait-listed period, this child required intermittent plasma exchange and pressors. Listing status evolved from PELD score 23 (5 days), to PELD score 40 (40 days), and status 1B for the last 10 days of life. Support was withdrawn for refractory hemodynamic failure by parental request, despite additional live-donor availability. Commendable efforts by UNOS, and its Pediatric, Liver, and Intestinal committees have yielded several initiatives to prevent this situation. An example is the preferential allocation of pediatric liver grafts to pediatric donors. However, a focused review of the UNOS Registry data for two 365-day periods, separated by a decade in which this initiative was implemented, suggests partial success. For 1995 and 2005 (Table 1), comparisons show that status 1 liver-alone wait-list mortality remained modest (19 deaths in 1995 and 13 deaths in 2005) but unchanged, when viewed as deaths per day. This is surprising because significantly fewer pediatric grafts were transplanted into adults in 2005, compared with 1995 (47.5% versus 63%, respectively). Also, pediatric recipients of pediatric liver grafts were similar in each year (n = 328 versus 320). Possible reasons include a shrinking denominator: 20% fewer pediatric liver grafts were obtained in 2005, compared with 1995. Second, another population competes increasingly with liver-alone candidates, for pediatric liver grafts. Compared with 1995, when only 39 of 989 pediatric liver grafts were transplanted with other organs, e.g., the intestine or kidney, nearly 3 times as many (n = 106) fit this category in 2005. Two findings by Rhee et al. can form the basis of a renewed dialogue on pediatric liver allocation for acute liver/graft failure. In multivariate models, the distance between the donor and recipient had no impact on posttransplant patient or graft survival. Also, liver grafts from children less than 6 years old had the best outcomes in pediatric recipients, while grafts from adults older than 34 years had worse outcomes. This would suggest that national sharing of the optimal resource for a high-risk population be reevaluated, in order to eliminate the modest annual mortality of n = 13–19 children listed as status 1. Specifically, liver grafts from donors younger than 6 years could be offered preferentially to status 1 liver-alone candidates, prior to regional/PELD-based allocation. Added to this, the different listing categories (status 1A, status 1B, PELD score of 40, etc.) currently allowed for children with acute liver failure, or the patient with the failed/failing liver graft, can give the appearance of our greater commitment toward one type of recipient over another. Practically, this has never been the case. The compassionate stance of regional committees permits appropriate consideration of the growing requests for “PELD exceptions”. Even so, need-based allocation must evolve toward more objective criteria, lest any committee, however compassionate, bear the burden of a wrongly denied request for “PELD exception”, in retrospect. A reasoned solution will require due consideration of opposing forces, e.g., increasing numbers of low-yielding pediatric DCD versus children requiring liver-intestinal grafts. While espousing such consideration, the end goal of net benefit cannot compromise further the outcomes of pediatric liver recipients, for whom the maintenance of expected survival outcomes appears to be at increasing risk. Rhee et al. deserve credit for renewing this dialogue. This work was supported in part by Health Resources and Services Administration contract 234-2005-370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Rakesh Sindhi MD, FACS*, Kyle Soltys MD*, Geoffrey Bond MD*, Amadeo Marcos MD*, George Mazariegos MD, FACS*, * Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA.