A 23-month-old donor supported on VA-ECMO provided a liver recovered using normothermic regional perfusion. The graft went to a child with maple syrup urine disease, whose native liver then benefited a second child with biliary atresia. Both had good early graft function, although postoperative complications occurred. This case illustrates the potential of combining pediatric DCD-NRP with domino transplantation, without establishing long-term safety or comparative benefit.
One Donation, Two Pediatric Liver Transplants
Anastasia M. Kahan and colleagues report an unusual combination of pediatric donation after circulatory death (DCD), normothermic regional perfusion (NRP), and domino liver transplantation. A liver recovered from a 23-month-old donor was transplanted into a four-year-old child with maple syrup urine disease (MSUD). That recipient’s explanted native liver was then transplanted into an 18-month-old child with biliary atresia. The sequence allowed one deceased-donor liver donation to support two pediatric liver transplants.
The authors describe this as the youngest DCD-NRP liver donor reported in the United States to their knowledge at publication. This is a geographically and temporally qualified claim, not a claim of the youngest donor worldwide. The report is particularly relevant to perfusion professionals because the donor’s existing venoarterial extracorporeal membrane oxygenation (VA-ECMO) access was repurposed for abdominal regional perfusion.
Donor Background and Regional Perfusion
The donor weighed 10.9 kg and had hypertrophic cardiomyopathy complicated by recurrent cardiac arrest. VA-ECMO was initiated during extracorporeal cardiopulmonary resuscitation using cervical cannulation. Despite stabilization, extensive hypoxic–ischemic brain injury developed. Following multidisciplinary discussions and the family’s decision to transition to comfort-focused care, donation proceeded under institutional DCD protocols.
The report describes 30 minutes from withdrawal of life-sustaining treatment to circulatory arrest, followed by a five-minute no-touch observation period. NRP began six minutes after circulatory death and 36 minutes after withdrawal. These reported intervals should not be confused with a separately defined functional warm ischemic time, which requires specified physiologic thresholds.
The team used the existing 14-Fr venous and 13-Fr arterial cannulas after surgically isolating the abdominal circulation from the cerebral and coronary circulations. The publication describes the isolation and confirmation performed by its team; the case narrative is not a complete technical protocol for reproducing this configuration. The distinction between systemic ECMO support and deliberately restricted regional perfusion is fundamental to understanding this report.
Perfusion Measurements and Organ Recovery
Abdominal NRP continued for 103 minutes, with reported pump flows between 1.7 and 2.1 L/min. Assessment included circuit hemodynamics, the appearance of the liver, serial blood gases, and metabolic trends. Lactate decreased from 12.4 to 9.9 mmol/L, while arterial pH increased from 7.02 to 7.6. The lactate improved but remained elevated, and the final pH was alkalemic; these data should not be described as normalization of all metabolic measurements.
The reported flows and laboratory values describe a single donor experience. They do not establish pediatric NRP flow targets, organ acceptance thresholds, or a standardized endpoint for recovery. Their educational value is in showing the combination of technical and metabolic observations used during this procurement, rather than in supplying a universally applicable operating prescription.
After NRP, the abdominal organs were recovered. Both kidneys were also recovered en bloc and transplanted into one adult recipient. The authors reported functioning kidney grafts at the last available follow-up, with a recipient creatinine of 0.8 mg/dL. Thus, the overall donation and domino sequence benefited two pediatric liver recipients and an adult kidney recipient.
How the Domino Sequence Worked
The first liver recipient was a four-year-old child with MSUD, a metabolic disorder requiring substantial dietary management and surveillance. Before transplantation, she remained at risk of metabolic decompensation despite treatment. The deceased-donor liver was transplanted to address that underlying metabolic problem. During removal of her native liver, the surgical team preserved the structures needed to prepare it for use as a domino graft.
The second recipient was an 18-month-old child with biliary atresia who had previously undergone Kasai portoenterostomy. Progressive disease, recurrent cholangitis, and portal hypertension persisted despite that operation. The native liver removed from the child with MSUD was implanted into this second recipient, with vascular reconstruction adapted to the anatomy and biliary reconstruction using the existing Roux limb.
This approach depends on careful metabolic and surgical selection. A liver removed for a metabolic indication is not automatically suitable for another recipient. The authors place their case within prior MSUD domino-transplant experience, in which satisfactory graft function and the absence of newly acquired MSUD have been reported. Those prior observations provide context, but they do not substitute for long-term metabolic surveillance of the recipients in this case.
Early Outcomes Included Important Complications
The first recipient initially recovered with improving liver enzymes and transfer out of intensive care on postoperative day one. She subsequently developed fever, abdominal symptoms, ascites, and increasing oxygen requirements. Exploratory laparotomy and washout were performed on day nine for a suspected intra-abdominal infectious source, followed by another washout and closure the next day. No anastomotic leak was identified, and cultures were negative.
Her recovery also included acute kidney injury and pleural effusion. With further treatment, nutritional advancement, and adjustment of immunosuppression, she improved. Serial branched-chain amino acid measurements trended appropriately, and she was discharged on postoperative day 17 with a liberalized diet. These findings support a favorable early metabolic and graft outcome while recognizing the substantial postoperative care required.
The domino recipient had excellent early graft function and was discharged on postoperative day six. Although the abstract characterizes this course as uncomplicated, the detailed case narrative describes coronavirus-associated pneumonia or bronchiolitis requiring high-flow nasal oxygen and intermittent hypertension. An accurate summary therefore distinguishes good graft function and early discharge from an entirely complication-free hospitalization.
Implications for Perfusion and Pediatric Transplant Programs
The report illustrates how regional perfusion and domino transplantation can address different parts of the donor shortage. NRP enabled assessment and recovery of abdominal organs after circulatory death, while the domino pathway extended the benefit of the liver donation to an additional child. Coordinating these steps required integration of donor management, perfusion, transplantation, metabolic expertise, and care for multiple recipients.
The authors also discuss family-centered consent, transparent donation processes, the observation period after circulatory arrest, and exclusion of cerebral circulation from regional reperfusion. Their discussion of pediatric allocation raises an additional policy question: whether pediatric DCD livers receive the same pediatric priority as other pediatric donor livers. This is presented as the authors’ policy concern at publication, rather than an independently verified statement of current allocation rules.
Evidence Limitations
This is one donor case with two pediatric liver recipients, no comparison group, and predominantly early outcome reporting. It demonstrates feasibility in a selected setting but cannot establish superiority over other procurement strategies, quantify uncommon complications, or determine long-term graft and metabolic outcomes. Larger multicenter experience and longer follow-up are needed to evaluate how broadly the combined approach can be applied.
Attribution: © 2026 The Authors. Published in Pediatric Transplantation by Wiley Periodicals LLC under a Creative Commons Attribution license. This independently written IPA summary accompanies the original research; cover artwork is conceptual.
Original Article
Kahan AM, van der Schyff F, Contreras AG, et al. Expanding the Donor Pool in Pediatric Transplantations: Successful Domino Liver Transplantation From the Youngest Reported Pediatric DCD Donor Using Normothermic Regional Perfusion in the United States. Pediatric Transplantation. 2026;30:e70498. Read the original article.
