Background: In Switzerland, children and adults alike are on the same national liver transplant (LT) waitlist. Over the last decades the Swiss liver allocation system has undergone significant regulatory reforms to ensure that children are not disadvantaged on the waitlist, the most important one being, from 2013, compulsory splitting in donors of <50 years for pediatric patients weighing ≤25 kg. This study aims to describe the waitlist-landscape of children in Switzerland in need of a LT, particularly by analyzing the impact of the “≤25 kg regulation”.

Methods: Analysis of waitlist data from the Swiss Organ Allocation System database of patients 0-16 years upon LT-listing, for Era 1: 07.2007-06.2013, Era 2: 07.2013-12.2023. For this descriptive analysis, no statistical tests were employed to analyze the data from the two eras because of small numbers in both cohorts.

Results: During Era 1 57 children (≤25 kg: 45) and during Era 2 96 children (≤25 kg: 62) were added to the waitlist. Waitlist mortality remained unchanged over time: 2% for all children, 2.9% for children ≤25 kg at LT. In children weighing ≤25 kg, between Era 1 and Era 2, a 10% increase of left lateral segment LT in non-urgent status was observed (45% vs. 55%), despite a decrease in young (<50 years old) donors. Median waiting time showed, for all patients a 13 days decrease between Era 1 and 2, from 58 days (interquartile range (IQR) 38-106) to 45 days (IQR 21-193); and for patients ≤25 kg a 42 days decrease, from 71 days (IQR 38-107) to 29 days (IQR 19-67).

Conclusion: The adaptation of the organ allocation rules in Switzerland has positively impacted pediatric LT, noticeably reducing waitlist times for small children. Advocacy must persist by consistently generating scientific data to enhance the future of children in need of LT.