Amy E. Gallo, MD
Assistant Professor of Surgery (Abdominal Transplantation)
Stanford University Medical Center
Low case volume is being associated with worse surgical outcomes, and transplantation is not an exception to this finding (1,2). As programs continue to be scrutinized by regulatory bodies to meet outcome measures, there have been fewer programs in the United States committed to pediatric transplantation. While the American Society of Transplant Surgeons has established surgical volume requirements for liver, kidney, pancreas, and small bowel for fellowship training program accreditation, there are no fellowship requirements specific to pediatric transplantation. Assuming that each organ requires specific individual training requirements—because of complexity of the underlying disease and technical variation—it can be argued that pediatric solid organ transplantation calls for vastly different medical and surgical approaches from those of the adult counterparts and, therefore, should have its own fellowship requirements per solid organ.
In addition, the UNOS Pediatric Transplant Committee has recently gained momentum on a motion to improve the quality and safety of pediatric transplantation. By the current OPTN Bylaws, the primary surgeon and primary physician in a pediatric transplant program are not required to have pediatric training or experience. The Pediatric Transplant Committee identified that OPTN data from 1995-2010 showed significantly better unadjusted Kaplan-Meier graft and patient survival for kidney, liver, and heart recipients from 1995-2010 at higher volume centers. Higher volume centers were defined differently for each organ: 12 for kidney, 18 for livers, 8 for hearts, and 4 for lungs, respectively. Over the period from 1/1/05-7/31/14, 65.5% of kidney and 58.0% of liver programs performing pediatric transplants met these criteria. The proposal by the UNOS Pediatric Transplant Committee requires that each transplant center have a primary pediatric transplant surgeon who meets the current Bylaws for a Primary Surgeon in addition to having performed 12 pediatric kidneys or 18 pediatric livers and participated for at least 2 years in organ-specific pediatric transplantation care. This proposal was presented to the Membership and Professional Standards Committee (MPSC) in September 2015. The MPSC is supportive of the proposal overall with the caveat that there be at least one qualifying program in each region by the time the requirements take effect.
If pediatric requirements are accepted, mandating similar volume criteria for surgical fellowship (performing 12 kidneys and 18 livers for pediatric certification) would convey the technical and management differences that exist in pediatric transplantation. Currently in the 119 modules the transplant fellows are required to complete in the ASTS Academic Universe, only 2 are specific to pediatric transplantation.
With certification targets in place, applicants interested in pediatric transplantation can seek out programs that will satisfy the requirements. Graduates of these programs may pave the way to a better understanding of these pediatric differences following completion of their training. They can embark on job opportunities that reflect their strengths or look to continue training with their deficits more clearly defined. That is not to say that someone with no pediatric fellowship training could not consider pediatrics as a job career, but like many graduates without pancreatic or intestine training, the understanding is that they will not lead a program without senior expertise and further exposure.
What continues to set transplant surgeons apart from other surgical fields is their lifelong commitment to patients, the reason that many of us chose the field. Setting fellowship requirements in pediatric transplantation might emphasize to trainees that performing a transplant on children means understanding and commanding issues unique to this patient population, such as the impact of psychomotor development as well as psychosocial issues, bone disease, inherited and sporadic syndromes, metabolic diseases, urologic anomalies, the effects of life-long immunosuppression, non-adherence particularly amongst adolescents, post-transplant lymphoproliferative disorders, and anatomic considerations (3,4). Embracing this knowledge allows us to advance the field of pediatric transplantation and reinforce our commitment to take care of such a fragile patient population.
1: Rana A, Pallister Z, Halazun K, Cotton R, Guiteau J, Nalty CC, O'Mahony CA, Goss JA. Pediatric Liver Transplant Center Volume and the Likelihood of Transplantation. Pediatrics. 2015 Jul;136(1):e99-e107. doi:10.1542/peds.2014-3016. Epub 2015 Jun 15. PubMed PMID: 26077479.
2: Schold JD, Buccini LD, Goldfarb DA, Flechner SM, Poggio ED, Sehgal AR. Association between kidney transplant center performance and the survival benefit of transplantation versus dialysis. Clin J Am Soc Nephrol. 2014 Oct 7;9(10):1773-80. doi: 10.2215/CJN.02380314. Epub 2014 Sep 18. PubMed PMID:25237071; PubMed Central PMCID: PMC4186511.
3. Davis ID, Bunchman TE, Grimm PC, Benfield MR, Briscoe DM, Harmon WE, Alexander SR, Avner ED. Pediatric renal transplantation: indications and special considerations. A position paper from the Pediatric Committee of the American Society of Transplant Physicians. Pediatr Transplant. 1998 May;2(2):117-29.Review. PubMed PMID: 10082443.
4. McDiarmid SV. Liver transplantation. The pediatric challenge. Clin Liver Dis. 2000 Nov;4(4):879-927. Review. PubMed PMID: 11232362. Have a different perspective? The ASTS Communications Committee would love to hear it. Log in to comment below or send your thoughts to firstname.lastname@example.org!