Introduction: Liver paired exchange (LPE) is a method to reduce donor ineligibility when blood type or size mismatches occur between a donor and recipient. Prior reports of LPE from North America have only highlighted transplants between adult recipients or a combination of adult and pediatric recipients. Here we present a successful case of LPE for two pediatric recipients with one-year outcomes.

Methods: A retrospective chart review was conducted aiming to present our initial experience with a pediatric LPE.

Results:  The paired exchange occurred September 2023 and included a 35-year-old male with to an unrelated 6-year-old female diagnosed with protein C deficiency. The second pair was an altruistic 39-year-old female to a four-month-old male with ornithine transcarbamylase deficiency (OTC), related to the first male donor. All patients were blood type O. Both infants received a left lateral segment graft with conventional anatomy. The LPE allowed for a more appropriate graft-to-recipient weight ratio (GRWR) for the infant recipient, 2.6% versus 4.2%, for a directed donation. The other child’s GRWR was well matched at 1.6% with the swap. Neither of the donors had complications and were doing well at 1-year follow-up. Both recipients returned to the operating room initially for complete and partial hepatic artery thrombosis requiring revision. One had a subsequent bile leak requiring biliary drainage. Both grafts were salvaged, and both recipients are alive with functional grafts at 16 months post-operatively.

Conclusion: Liver paired exchange between two pediatric recipients can reduce size incompatibilities and one-year outcomes support continued programmatic growth. Early identification and treatment of complications can also reduce graft loss.