Pediatric Donor Research Articles

Overcoming problematic growth phenotypes in organoids from patients with monogenic GI disease.

Patient-derived organoids provide a unique model system to explore disease-causing mutations ex vivo. By using organoids from duodenal or colonic biopsies of pediatric patients with intestinal epithelial disorders, we can directly assay the patient cells to tailor treatment to their unique disease state. The advent of organoid technology from patients with severe intestinal disorders such as Congenital Diarrhea Enteropathies (CoDE) and Very-Early-Onset Inflammatory Bowel Disease (VEO-IBD) has allowed for rapid advances in the understanding of and the treatment of these monogenic disorders. Still, the expansion of these lines for scalable studies is not trivial, and success rates of expansion are variable between groups, and even lab members within the same group. These protocols have been validated on patients with CoDE or VEO-IBD and age-matched control patients. Here, we present our recommended protocols for the cultivation of organoids from pediatric patients with CoDE and VEO-IBD. These protocols have been validated on organoids generated from the duodenum (duodenoids), ileum (ileoids), colon (colonoids) and iPSC-derived intestinal colonoids from pediatric healthy donors or donors with CoDE or VEO-IBD (Gwilt et al., 2023). Using our modified culture media, extended culture times from biopsy preparation and thawing frozen lines, gentle passaging techniques with the incomplete removal of the organoids from the matrigel, and modified monolayer protocols (Maeda et al., 2023; Maeda et al., 2022), we have been able to successfully culture and expand several lines for more than 5 years. The conditions and protocols used here provide a basis for reproducible phenotypes, scaling for larger functional studies on patient lines, and for reproducibility of results between several investigators. We provide a useful starting point and troubleshooting guidelines for the optimization of culturing organoids from any patient with novel disease pathology.

Use of Hepatitis C Viremic Donors to Expand the Pediatric Donor Pool

The use of hepatitis C virus (HCV)-positive donors in organ transplantation has become increasingly viable due to advancements in direct-acting antiviral (DAA) therapies, which offer high cure rates. This review aims to evaluate the current practices, benefits, and challenges of utilizing HCV-positive donors for organ transplantation. The recent data show that transplant centers are progressively accepting HCV-positive donors for various organs, including kidneys, livers, and hearts, given the efficacy of post-transplant antiviral treatment. Using these donors has helped mitigate the organ shortage crisis, increasing the donor pool and reducing waitlist times. Despite these advantages, the approach raises concerns about viral transmission, long-term outcomes, and the cost-effectiveness of post-transplant DAA therapy. Furthermore, this review highlights the ethical implications of informed consent and the monitoring of HCV-negative recipients following transplantation. The outcomes from recent studies suggest that with proper management, transplantations from HCV-positive donors to HCV-negative recipients can be safe and effective, leading to excellent graft function and patient survival. This review synthesizes existing research and offers insights into optimizing protocols for future transplants involving HCV-positive donors.

They Deserve to Live: Impact of the Berlin Heart EXCOR on Small Children's Heart Transplant Waitlist in Low-Resource Settings.

Background: In newly emerging economy countries, the shortage of pediatric donor hearts and poor healthcare infrastructure poses a significant challenge. Although mechanical circulatory support (MCS) has been proven effective in enhancing heart transplant waiting list outcomes, economic barriers hinder its widespread adoption. Methods: A single-center retrospective study reviewed children under 10 kg on the heart transplant (HTx) list from 2012 to 2023. Elective or priority status was assigned based on their clinical condition at the time of transplant. In cases of clinical decompensation, centrifugal pump and extracorporeal membrane oxygenation, transitioned to the Berlin Heart EXCOR (BHE) pediatric ventricular assist device (VAD) was employed. Pre- and post-HTx outcomes were analyzed with descriptive statistics, Cox regression, and competing survival risks. Results: Out of 81 infants on the HTx list, 61.7% (50/81) were in critical condition. The median wait time was 224 days, and 34% (28/81) died while waiting. Out of 37 transplanted patients, 6 (16%) had graft dysfunction, and 10 (27%) had acute renal injury. Survival to discharge was 84% (31/37). Patients who received the BHE exhibited higher chances of receiving a transplant (hazard ratio: 2.3; 95% confidence interval: 1.2-4.6; P = .01). Priority status or MCS use did not significantly impact mortality post-transplant. Conclusion: Advanced MCS technologies can potentially reduce the mortality risk on the pediatric HTx waitlist. The findings highlight the significant waiting time for HTx and the critical role of the BHE in improving outcomes in children, particularly those under 10 kg. The results advocate for the adoption of ventricular assist devices as a viable interim solution to bridge critically ill children to HTx, ultimately enhancing their chances of survival despite limited donor heart availability.

Interferon-β-Induced Injury During Pediatric Muscle Differentiation: Insight Into Juvenile Dermatomyositis Pathogenesis.

Juvenile dermatomyositis (JDM) involves up-regulated type I interferons (IFNs), including IFNβ, yet pathologic mechanisms remain poorly understood. We aimed to characterize the functional and structural effects of IFNβ on in vitro human pediatric myoblast growth and differentiation in a three-dimensional skeletal muscle model (myobundles). Myobundles fabricated from myoblasts of a healthy pediatric donor were exposed to IFNβ at 0 to 5,600 IU/mL during growth (days 1-4), differentiation (days 4-11), and/or mature (days 11-18) periods. To assess myobundle structure and function, contractile force, kinetics, and fatigue were measured at day 18 with subsequent immunohistochemistry. Myobundles were not functionally affected by IFNβ exposure during growth period alone. However, when IFNβ exposure continued through differentiation, myobundles became dysfunctional (P < 0.0001). IFNβ during differentiation or mature periods alone resulted in dose-dependent decreases in contractility, with greater decrease in the differentiation alone group (P < 0.0001). Twitch kinetics and fatigue remained largely unchanged when myobundles were exposed to IFNβ only during growth, yet twitch time slowed (P < 0.005) and fatigue decreased (P < 0.002) when myobundles were exposed during differentiation or mature stages alone. Nuclei density and myofiber size and organization also decreased when IFNβ was added during differentiation period alone. IFNβ decreases pediatric myobundle contractile function most significantly during differentiation of myoblasts to myotubes. Function is not affected when IFNβ exposure is limited to myoblast proliferation alone. These findings implicate a pathologic role for IFNβ in JDM by impairing myoblast differentiation, leading to subsequent loss of function and ongoing need for muscle regeneration and repair.

Prediction of Whole Liver Graft Weight Based on Biometric Variables in Paediatric and Adult Liver Donors.

In paediatric liver transplantation, donor-recipient compatibility depends on graft size. We explored whether the graft weight can be predicted using the donor's biometric parameters. We used seven easily available biometric variables in 142 anonymised paediatric and adult donors, with data collected between 2016 and 2022. The whole or partial liver was transplanted in our hospital from these donors. We identified the variables that had the strongest correlation to our response variable: whole liver graft weight. In child donors, we determined two linear models: using donor weight and height on the one hand and using donor weight and right liver span on the other hand. Both models had a coefficient of determination R2 = 0.86 and p-value < 10-5. We also determined two models in adult donors using donor weight and height (R2 = 0.33, p < 10-4) and donor weight and sternal height (R2 = 0.38, p < 10-4). The models proved valid based on our external dataset of 245 patients from two institutions. In clinical practise, our models could provide rapidly accessible estimates to determine whole graft dimension compatibility in liver transplantation in children and adults. Determining similar models predicting the left lobe and lateral segment weight could prove invaluable in paediatric transplantation.

Perioperative Anesthetic Management and Outcome of a Cadaveric Pediatric En-bloc Kidney Transplantation: A Case Report

Kidney transplantation stands as the favored approach to treat end-stage renal disease in children, offering enhanced survival, improved quality of life, and better neuropsychological development compared to dialysis. Transplanting kidneys en bloc remains a complex procedure, diverging from the conventional single kidney transplantation in several aspects, requiring precise skill and expertise to achieve favorable outcomes. In this paper, we report a successful en-bloc kidney transplantation from a 16-month-old pediatric cadaveric donor to a 5-year-old recipient, the youngest individual to undergo an en-bloc kidney transplant in the country, and the contribution of meticulous anesthetic management to this success story.

Paediatric donor lung preservation using Paragonix BAROguard.

Paediatric lung transplantation is a lifesaving option in selected patients with end-stage lung disease. Favourable long-term outcomes are limited by impaired mucus clearance, increased risk of infection resulting from immunosuppression, and chronic lung allograft dysfunction. Organ preservation techniques play an important role in the quality of donated organs. Barotrauma to donated lungs may arise from a combination of excessive recruitment manoeuvres and altitude change during air transportation. The Paragonix BAROguard Donor Lung Preservation System is an FDA-approved advanced organ recovery system that maintains continuous airway pressure of 15 cm of water during transportation of the donated lung(s) to the recipient. The Paragonix LUNGguard monitors temperature during transportation of donor lung(s), while the new BAROguard monitors both temperature and pressure during transportation of donor lung(s). In this publication, we present technical aspects of advanced preservation of paediatric donor lungs using the Paragonix BAROguard Donor Lung Preservation System.

Pediatric Organ Donation: 16-Year Experience of PICU/ICU of a Third Level Hospital in Portugal, 2006-2021.

Although pediatric organ donation represents a small proportion of overall organ donation, children and adolescents make a significant contribution to the pool of donated organs. In this study 252 solid organs were collected from children and adolescent. Two hundred and two recipients benefited from 62 pediatric organ donors, with a recipient/donor ratio of 3.3.

Small Donors, Big Impact: Optimizing Organ Utilization in Simultaneous Pancreas and Kidney Transplantation From Extra Small Pediatric Donors.

Simultaneous pancreas-kidney transplantation (SPK) is the preferred treatment for individuals with type-1 diabetes and end-stage renal disease. However, a limited supply of "Ideal Pancreas Donors" contributed to a growing disparity between available organs and recipients. Even though SPK outcomes from pediatric donors match those from adult donors, unclear guidelines on minimum age and weight criteria for extra small pediatric pancreas donors lead to hesitancy among several transplant centers to utilize these grafts due to concerns about inadequate islet mass, technical challenges, and increased risk of allograft thrombosis. This report details the successful outcomes of SPK transplantations performed at the study center between December 2021 and January 2024, using four extra small pediatric brain-dead donors (ESPDs). Each donor was aged ≤5 years and weighed <20kg. All SPK recipients achieved immediate posttransplant euglycemia without requiring insulin. None of the recipients experienced graft pancreatitis, graft thrombosis, allograft rejection, or required re-exploration. During a 5-27-month follow-up period, all ESPD recipients maintained optimal graft function, as evidenced by normal glucose tolerance tests and HbA1c (4.9%-5.2%), with 100% graft and patient survival. This report examines the usage of ESPDs in SPK transplantation, highlighting their potential to expand the donor pool and reduce wait times in areas with scarce deceased organ donations, thereby increasing the number of available organs for transplantation with acceptable outcomes. Revising donor selection guidelines to reflect the diverse risk-benefit profiles of waitlisted individuals is crucial to addressing geographical disparities and reducing organ discard rates.

P.285: Simultaneous pancreas and kidney transplantation from a small pediatric donor with ipsilateral implantation over aortic cuff.

P.285: Simultaneous pancreas and kidney transplantation from a small pediatric donor with ipsilateral implantation over aortic cuff.

Ontogeny of Hepatic Organic Cation Transporter-1 in Rat and Human.

The organic cation transporter (OCT)-1 mediates hepatic uptake of cationic endogenous compounds and xenobiotics. To date, limited information exists on how Oct1/OCT1 functionally develops with age in rat and human livers and how this would affect the pharmacokinetics of OCT substrates in children or juvenile animals. The functional ontogeny of rOct/hOCT was profiled in suspended rat (2-57 days old) and human hepatocytes (pediatric liver tissue donors: age 2-12 months) by determining uptake clearance of 4-[4-(dimethylamino)styryl]-N-methylpyridinium iodide (ASP+) as a known rOct/hOCT probe substrate. mRNA expression was determined in rat liver tissue corresponding to rat ages used in the functional studies, while hOCT1 mRNA expressions were determined in the same hepatocyte batches as those used for uptake studies. Maturation of rOct/hOCT activity and expression were evaluated by comparing values obtained at the various ages to the adult values. Relative to adult values (at 8 weeks), ASP+ uptake clearance in suspended rat hepatocytes aged 0, 1, 2, 3, 4, 5, and 6 weeks reached 26%, 29%, 33%, 37%, 72%, 63%, and 71%, respectively. Hepatic Oct1 mRNA expression was consistent with Oct activity (correlation coefficient of 0.92). In human hepatocytes, OCT1 activity was age dependent and also correlated with mRNA levels (correlation coefficient of 0.88). These data show that Oct1/OCT1 activities and expression mature gradually in rat/human liver, thereby mirroring the expression pattern of organic anion transporting polypeptide in rat. These high-resolution transporter ontogeny profiles will allow for more accurate prediction of the pharmacokinetics of OCT1/Oct1 substrates in pediatric populations and juvenile animals. SIGNIFICANCE STATEMENT: Organic cation transporter-1 (OCT1) represents a major drug uptake transporter in human liver. This study provides high-resolution data regarding the age-dependent function of OCT1 in the liver, based on in vitro experiments with rat and human hepatocytes obtained from donors between birth and adulthood. These ontogeny profiles will inform improved age-specific physiologically based pharmacokinetic models for OCT1 drug substrates in neonates, infants, children, and adults.

Improved survival of pediatric deceased donor liver transplantation recipients after introduction of the pediatric prioritization system: Analysis of data from a Japanese national survey.

In Japan, there has never been a national analysis of pediatric deceased donor liver transplantation (pDDLT) based on donor and recipient factors. We constructed a Japanese nationwide database and assessed outcomes of pDDLT focusing on the pediatric prioritization system introduced in 2018. We collected data on pDDLTs (<18 years) performed between 1999 and 2021 from the Japan Organ Transplant Network and Japanese Liver Transplantation Society, identified risk factors for graft survival and compared the characteristics and graft survival in pDDLTs conducted before and after the introduction of the pediatric prioritization system. Overall, 112 cases of pDDLT were included, with a 1-year graft survival rate of 86.6%. Four poor prognostic factors were identified: recipient intensive care unit stay, model for end-stage liver disease/pediatric end-stage liver disease score, donor cause of death, and donor total bilirubin. After the introduction of the system, allografts from pediatric donors were more reliably allocated to pediatric recipients and the annual number of pDDLTs increased. The 1-year graft survival rate improved significantly as did pDDLT conditions indicated by the risk factors. Under the revised allocation system, opportunities for pDDLT increased, resulting in favorable recipient and donor conditions and improved survival.

Bladder and Kidney Transplantation En Bloc: Review of Experience and Prospects for Development.

Although urine bladder transplantation is currently being conducted, the procedure is an incompletely resolved problem in clinical transplantology. A small number of en bloc bladder and kidney transplants from pediatric donors to adult recipients in humans have been reported. A small number of bladder transplants with and without combinations with kidneys have also been performed in experiments on different animal models. Here, we aimed to highlight the experiences of various scientists in bladder transplantation in humans and animals. We also presented our small experience in conducting transplant of 1 kidney, ureters, and a segment of the bladder in an experiment on pigs in 2023 (5 cases), which is a promising direction for further successful development of this technology in humans. In 2024, we plan to conduct another 10 transplants of a single block ofthe kidney and bladderin pigs, results of which will be published after the completion of the experimental work.

Correlation Between Serum Transaminase Levels and Estimated Glomerular Filtration Rate After Living-Donor Kidney Transplantation

BackgroundThere is a risk of hypoperfusion during kidney transplantation surgery owing to patients’ underlying disease and ischemia-reperfusion injury; further, hypoperfusion may cause injury to major organs. We hypothesized that the decrease in blood pressure after ischemia-reperfusion injury during kidney transplantation may be associated with indicators of liver injury and kidney graft function. MethodsData regarding living-donor kidney transplantations performed at our institution between 2018 and 2022 were retrospectively evaluated. Exclusion criteria included pediatric recipients or donors aged <18 years, multiple organ transplantation, and elevated postoperative serum transaminase levels. Correlations among blood pressure, serum transaminase levels on postoperative days 3 to 5, and estimated glomerular filtration rate (eGFR) on postoperative days 7 and 14 were analyzed. Further, a subgroup analysis was performed based on eGFR. ResultsA total of 276 patients were included in the final analysis. Serum transaminase levels were significantly negatively correlated with eGFR (partial correlation coefficient—0.26, P < .001). The postreperfusion decrease in blood pressure was not correlated with serum transaminase levels. However, the postreperfusion decrease in blood pressure and baseline blood pressure correlated with the eGFR (partial correlation coefficient = −0.18, P = .004). ConclusionThese findings indicate a correlation between intraoperative liver injury and kidney graft function, suggesting the importance of intraoperative management of organ perfusion. Since postreperfusion blood pressure changes did not significantly correlate with liver injury indicators, it is important to consider other causative factors for hypoperfusion in major organs during living-donor kidney transplantation, including microcirculatory failure and organ congestion-related ischemia/reperfusion.

A comprehensive, multifaceted strategy to increase pediatric donor heart utilization

BACKGROUNDMany hearts offered for pediatric heart transplantation (HT) are not placed. In 2016, we initiated a quality improvement endeavor to increase heart offer acceptance. This study assessed the effect of these interventions at our center. METHODSEvaluation of pre-/post-implementation cohorts (1/1/2008-12/31/2016 vs. 1/1/2017- 7/1/2023) comparing donor heart utilization. Six interventions were iterated over time to increase offer acceptance (“extended criteria”): ABO-incompatible transplant, ex vivo perfusion for distanced donors, 3-dimensional total cardiac volume (TCV) assessment, acceptance of Hepatitis-C or SARS-COV-2 infected donors, and institutional culture change favoring consideration of donors previously considered unacceptable (Public Health Service Risk, long CPR duration, etc.). Outcomes studied included annual HT volume, median waitlist duration, sequence number at acceptance, and post-transplant clinical outcomes. RESULTSFrom 1/2008–7/2023 annual transplant volume increased from 16/year to 25/year pre-/post-implementation. Three hundred-thirteen/389 (80%) listed patients were transplanted. Waitlist duration shortened post-implementation (P=0.01), as did the percentage of accepted heart offers utilizing at least one extended criterion (P<0.001). Institutional culture change and TCV assessment had the largest impact on donor heart utilization (P=0.04 &P<0.001). There was no difference in post-HT intubation or cardiovascular intensive care unit (CVICU) days (P= 0.05-0.9), though post-transplant hospitalization duration (P<0.001) increased. Post-transplant survival was unaffected by use of extended criteria hearts (P=0.3). CONCLUSIONSWe report increased donor heart offer acceptance resulting from a longitudinal, multi-faceted effort to increase organ offer utilization, with institutional culture change and TCV assessments having the greatest impact. Use of extended criteria hearts was not associated with inferior survival.

Graft Survival of En Bloc Deceased Donor Kidneys Transplants Compared With Single Kidney Transplants.

The US Kidney Allocation System allocates en bloc deceased donor kidney grafts from donors <18 kg in sequence A along with single kidney transplants (SKTs) from kidney donor profile index (KDPI) top 20% donors. Although en bloc grafts outperform SKT grafts holding donor weight constant, it is unclear if en bloc grafts from the smallest pediatric donors perform the same as top 20% KDPI SKTs. Using the Scientific Registry of Transplant Recipients, we compared the donor characteristics and graft survival of en bloc grafts from the smallest donors (<8 kg) and from larger donors (≥8 kg) with SKTs by KDPI sequence for transplants performed in 2021. Larger donor en blocs had similar 1-y survival to sequence A SKTs estimated by the Kaplan-Meier method (96% versus 96%, P = 0.9), but the smallest donor en blocs had significantly shorter 1-y survival than those SKTs (80% versus 96%, P < 0.01). Using transplants from 2010 to 2012, the smallest donor en blocs had similar 10-y survival to sequence A SKTs (69% versus 64%, P = 0.3). These findings suggest that future updates of the Kidney Allocation System should include a score specific to pediatric donors to account for these differences in en bloc graft survival.

Dissecting thrombus-directed chemotaxis and random movement in neutrophil near-thrombus motion in flow chambers.

Thromboinflammation is caused by mutual activation of platelets and neutrophils. The site of thromboinflammation is determined by chemoattracting agents release by endothelium, immune cells, and platelets. Impaired neutrophil chemotaxis contributes to the pathogenesis of Shwachman-Diamond syndrome (SDS). In this hereditary disorder, neutrophils are known to have aberrant chemoattractant-induced F-actin properties. Here, we aim to determine whether neutrophil chemotaxis could be analyzed using our previously developed ex vivo assay of the neutrophils crawling among the growing thrombi. Adult and pediatric healthy donors, alongside with pediatric patients with SDS, were recruited for the study. Thrombus formation and granulocyte movement in hirudinated whole blood were visualized by fluorescent microscopy in fibrillar collagen-coated parallel-plate flow chambers. Alternatively, fibrinogen, fibronectin, vWF, or single tumor cells immobilized on coverslips were used. A computational model of chemokine distribution in flow chamber with a virtual neutrophil moving in it was used to analyze the observed data. The movement of healthy donor neutrophils predominantly occurred in the direction and vicinity of thrombi grown on collagen or around tumor cells. For SDS patients or on coatings other than collagen, the movement was characterized by randomness and significantly reduced velocities. Increase in wall shear rates to 300-500 1/s led to an increase in the proportion of rolling neutrophils. A stochastic algorithm simulating leucocyte chemotaxis movement in the calculated chemoattractant field could reproduce the experimental trajectories of moving neutrophils for 72% of cells. In samples from healthy donors, but not SDS patients, neutrophils move in the direction of large, chemoattractant-releasing platelet thrombi growing on collagen.

Outcomes in pediatric recipients of single kidney transplantation from pediatric donors with acute kidney injury: A single-center pilot study.

Outcomes in pediatric recipients of single kidney transplantation from pediatric donors with acute kidney injury: A single-center pilot study.

"Take it or leave it": Analysis of pediatric heart offers for transplantation in Switzerland.

There is a shortage of donor hearts in Switzerland, especially for pediatric recipients. However, the rate and reason for refusals of pediatric donor hearts offered in Switzerland has not been systematically analyzed. The national transplant database, Swiss Organ Allocation System, was searched for all hearts from Swiss and foreign donors younger than 16 years from 2015 to 2020. The numbers of accepted and refused hearts and early outcome were assessed, and the reasons for refusal were retrospectively analyzed. A total of 136 organs were offered to the three Swiss pediatric heart centers and foreign donor procurement organizations. Of these, 26/136 (19%) organs were accepted and transplanted: 18 hearts were transplanted in Switzerland, and 13 of these were foreign. Reasons for refusal were (1) no compatible recipient due to blood group or weight mismatch, 89.4%; (2) medical, meaning organ too marginal for transplantation, 7.4%; (3) logistic, 1.4%; and (4) other, 1.8%. Five organs were refused in Switzerland by one center but later accepted and successfully transplanted by another center. Hearts from outside Switzerland were transplanted significantly less than Swiss hearts (n = 16/120 vs. 10/16, p < .001). The most common reason for refusing a pediatric donor heart is lack of compatibility with the recipient. Few hearts are refused for medical reasons. A more generous acceptance seems to be justified in selected patients. Switzerland receives a high number of foreign offers, but their rate of acceptance is lower than that of Swiss donations.

The state of paediatric deceased-organ donation at a South African tertiary public- sector hospital: A 14-year analysis.

Solid-organ transplantation (SOT) has been proven to be a highly effective and life-saving treatment modality for adults and children suffering from end-stage organ failure. However, high paediatric waiting-list mortality has been reported, and children may suffer irreversible physical and deleterious psychological effects if not transplanted timeously. To identify in-hospital barriers to organ donation and gain a better understanding of the paediatric donor landscape. A retrospective descriptive study of consecutive deceased-donor referrals at Red Cross War Memorial Children's Hospital over a 14-year period, from 1 January 2007 to 31 December 2020. During the study period, 156 in-hospital deaths were recorded in the trauma unit and 1 425 in the paediatric intensive care unit. Ninety-three of the 1 581 patients (5.9%) were referred to the on-call transplant co-ordinator as potential organ donors, of whom 69% had been involved in a traumatic accident, including 52% in road traffic collisions. The mean age of the potential donors was 7 years with 60.2% being boys. On initial assessment, 67 of the 93 potential donors (72%) were assessed as eligible for donation of at least one solid organ. The transplant co-ordinator attempted to approach all families for consent; however, five families/next of kin could not be located despite multiple attempts. Among the remaining 62 eligible donors, 44 families/next-of-kin declined consent for solid-organ donation, resulting in a consent rate of 29% (n=18). Several families refused consent for religious reasons. One of the consented donors did not proceed to procurement as there were no suitable recipients. Seventeen donors proceeded to theatre, the intention being solid-organ procurement, but in 2 donors the organs were assessed as being unsuitable for transplant. From the remaining 15 donors, a total of 46 organs were procured and successfully transplanted: 14 livers, 30 kidneys and 2 hearts. During the 14-year study period, only 15 deceased donors could be utilised for SOT, as a result of low in-hospital referral (5.9%) and consent rates (29%). The reasons for low referral and consent rates are complex and often multifactorial, which the current study was not designed to investigate in sufficient detail. Future studies should be designed to further interrogate our findings, while accommodating for nuances specific to the paediatric deceased-donor population and their families.