Impact of the pediatric ABO policy change on listings, transplants and outcomes for children younger than 2 years listed for heart transplantation in the U.S.: ABO incompatible pediatric heart transplantation

Document Type

Journal Article

Publication Date



Journal of cardiac failure




ABO incompatible; Organ Procurement and Transplantation Network; Scientific Registry of Transplant Recipients; post-heart morbidity; post-heart transplant survival; waitlist survival


BACKGROUND: We assessed the impact of the liberalized ABO pediatric policy change on candidate characteristics and outcomes for children undergoing heart transplant (HT). METHODS: Children <2 years undergoing HT with ABO strategy reported at listing and HT from 12/2011-11/2020 to the Scientific Registry of Transplant Recipients database were included. Characteristics at listing, HT and outcomes during the waitlist and post-transplant were compared pre- (12/16/11 - 7/6/16), and post-policy change (7/7/16-11/30/20). RESULTS: The percentage of ABO incompatible (ABOi) listings did not increase immediately post-policy change (p=0.93), however, ABOi transplants increased by 18% (p<.0001). At listing, both pre- and post-policy change, ABOi candidates had higher urgency status, renal dysfunction, lower albumin and required more cardiac support (IV inotropes, mechanical ventilation) than those listed ABO compatible (ABOc). On multivariable analysis, there were no differences in waitlist mortality between children listed ABOi compared to ABOc pre-policy (aHR 0.80, 95% CI 0.61-1.05, p=.10) or post-policy change (aHR 1.2, 95% CI 0.85-1.6, p=0.33). Post-transplant graft survival was worse for ABOi transplanted children pre-policy (aHR 1.8, 95% CI 1.1-2.8, p=.014), but not significantly different post-policy change (aHR 0.94, 95% CI 0.61-1.4, p=.76). Post-policy change, ABOi listed children had significantly shorter waitlist times (p<0.05). CONCLUSION: The recent pediatric ABO policy change has significantly increased the percentage of ABOi transplantations and decreased waitlist times for children listed ABOi. This change in policy has resulted in broader applicability and actual performance of ABOi transplantation with equal access to ABOi or ABOc organs, and thus eliminated potential disadvantage of only secondary allocation to ABOi recipients.