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

ABSTRACT Introduction Normothermic regional perfusion (NRP) during donation after circulatory death (DCD) improves abdominal organ utilization by limiting warm ischemia time. Its application in young pediatric donors remains exceptionally rare; the youngest previously reported DCD‐NRP donor in the United States was 5 years of age. Methods We describe DCD‐NRP organ procurement from a 23‐month‐old donor and the subsequent use of the liver graft in a domino liver transplantation involving two pediatric recipients. The kidneys were recovered en bloc. The donor, supported on veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) following hypoxic–ischemic injury, underwent DCD‐NRP using the preexisting ECMO cannulation after thoracic exclusion of the cerebral and coronary circulations. The recovered graft was transplanted into a 4‐year‐old with maple syrup urine disease (MSUD), whose explanted native liver was then used as a domino graft for an 18‐month‐old with biliary atresia. Results NRP was established rapidly with restoration of metabolic activity, and both transplants were technically successful with good early graft function. The MSUD recipient underwent re‐laparotomy for a suspected intra‐abdominal source of sepsis (no anastomotic leak identified; cultures negative) and recovered with appropriately trending branched‐chain amino acid levels, and was discharged on posttransplant Day 17. The domino recipient had an uncomplicated course and was discharged on posttransplant Day 6. Conclusion To our knowledge, this is the youngest DCD‐NRP liver donor reported in the United States and the youngest domino liver transplantation performed using a DCD‐NRP graft. Deliberately pairing NRP with domino transplantation may synergistically expand the critically limited pediatric donor pool.