Introduction: Children´s access to liver transplant in Spain was significantly lower compared to adults because only pediatric donors, which are very scarce, were offered for pediatric recipients. This inequity was historically compensated by the extended use of living donation. In 2019, the Organización Nacional de Trasplante (ONT) established a new allocation policy to promote split liver donation in young brain death donors.

Aim: To analyze the impact of the new <35years-split policy on the pediatric waiting list and the need of living donation.

Material and methods: The <35y-split policy established that all donors were offered to pediatric groups for consideration of split liver donation. The data from the ONT registry corresponding to 2018 and 2021 were compared. The period of 2019-2020 was excluded because of the pandemic and the possible interference of the transitional period.

Results: After the <35years-split policy implementation, the pediatric waiting list showed a 60% reduction (32 vs 14 active patients). Pediatric transplant probability was significantly improved (38% vs 73%, p<0.05), while the probability in adults remained stable (68% vs 65%). Time on the waiting list also improved in children (72 vs 27 days, p<0.05) with a minor impact in adults (48 vs 69 days, p=ns). Children´s Mortality on the waiting list experienced a 40% reduction. The need of living donation dramatically reduced (20/y vs 1/y, p<0.05).

Conclusions: The introduction of the <35years-split policy by the ONT significantly improved the access of the pediatric population to liver transplant without a negative impact on the adult waiting list. The use of living donor was reserved to selected cases although not completely eliminated.