Pediatric Organ Transplantation in China

ABSTRACT

China's growing healthcare system, serving over 1.4 billion people, has witnessed remarkable progress in organ transplantation, including among pediatric patients. This review provides a comprehensive overview of pediatric transplantation in China, summarizing national trends, regulatory frameworks, clinical outcomes, and ongoing challenges. Data were obtained from the Report on Organ Donation and Transplantation in China (RODTC) between 2015 and 2024. Pediatric patients were defined as those under 18 years of age. Following the 2015 reforms establishing voluntary citizen donation as the only legitimate organ source, China has developed a robust national regulatory and ethical framework under the National Health Commission. The China Organ Transplant Response System (COTRS) ensures transparent allocation, with a 2018 policy granting priority to pediatric recipients and mandating that organs from donors under 18 be preferentially allocated to pediatric patients. From 2015 to 2024, pediatric kidney, liver, and lung transplants increased 4.9‐, 2.1‐, and 7.5‐fold, respectively; pediatric heart transplantation increased 2.5‐fold from 2019 to 2024. In 2019, child donors represented 8.20% of deceased donors. Leading indications included non‐ischemic cardiomyopathy for heart, bronchiolitis obliterans for lung, biliary atresia and metabolic liver disease for liver, and glomerulonephritis for kidney transplantation. Reported survival rates were favorable, with 5‐year patient survival of 70.0% for heart and 95.5% for kidney transplants. Major transplant centers are concentrated in Shanghai, Guangzhou, Zhengzhou, and Beijing. Four national registries ensure lifelong follow‐up and quality monitoring. Pediatric organ transplantation in China has advanced rapidly under strengthened ethical oversight and allocation reforms prioritizing children. Despite significant growth, challenges remain in data accessibility, regional disparities, and donor shortages. Continued policy refinement, registry expansion, and regional collaboration—particularly with Hong Kong and Macao—are essential to further improve access and outcomes for pediatric transplant recipients.

1. Introduction

China, as the world's most populous country with a population exceeding 1.4 billion and a land area of approximately 9.6 million square kilometers, presents unique challenges and opportunities in healthcare. The country's GDP reached approximately 18.7 trillion USD in 2024, making it the second‐largest economy globally [1]. However, significant disparities exist between urban and rural areas, with rural regions accounting for 34% of the population but often lacking advanced healthcare facilities [2]. China's life expectancy at birth has improved by 6.8 years from 70.8 years in 2000 to 77.6 years in 2021, reflecting progress in healthcare accessibility and quality, though regional and socioeconomic inequalities persist [3]. While the national insurance system provides coverage for over 95% of the population, gaps persist, particularly in specialized care [4].

Organ transplantation remains a lifesaving standard of care and is the optimal treatment for organ failure. Historically, children receiving organ transplants experienced worse outcomes regarding patient and graft survival in comparison to their adult counterparts [5]. Pediatric organ transplantation presents distinct challenges, including the impact on growth and physical development, neurocognitive maturation, increased susceptibility to primary viral infections, and the presence of congenital or inherited comorbidities [6]. Advancements in immunosuppressive therapies, vaccination, anti‐infective agents as well as pre‐ and post‐transplant care have substantially improved outcomes in pediatric transplantation over recent decades—often surpassing those seen in adult recipients [7, 8].

Globally, the number of organ transplants has increased 9.5% from 2022 to 2023 [9]. In China, the past decades have shown a significant growth in both adult and pediatric transplantations. This review aims to provide a comprehensive overview of pediatric transplantation in China, highlighting recent advancements, current challenges, and future directions in clinical practice and policy.

2. Government Oversight and Regulatory Framework

The governance of organ transplantation in China is underpinned by a robust regulatory framework and an organized national structure at length described recently [10]. The Regulation on Human Organ Donation and Transplantation, first released in 2007 by the State Council and revised in 2023, provides the foundation for the national organ donation and transplantation system, effective as of May 1, 2024. This regulation reinforces the principles of voluntary, informed, and unpaid donation, aligning with a strict consent model. Accordingly, every citizen has the right to donate their organs or to decline without being pressured, deceived, or otherwise influenced. Donors must have full legal capacity and must provide written consent, which can be freely revoked at any time. No organs may be retrieved from living donors under the age of 18. Furthermore, if a person has explicitly refused organ donation during their lifetime, no organs may be retrieved or donated postmortem. In the absence of such a refusal, the spouse, adult children, or parents of the deceased may provide written consent for donation.

Since the 2015 reforms, voluntary citizen donation has become the sole legitimate source of transplantable organs, eliminating prior reliance on controversial procurement. Commercial transactions involving organs are strictly prohibited. Oversight is centralized under the National Health Commission (NHC), which supervises policy implementation, ethical compliance, and system integrity. The China Organ Transplant Response System (COTRS) serves as the national platform for organ registration and allocation, ensuring transparency and fairness.

Organ donation in China encompasses both deceased and living donors. Deceased donation is permitted following either brain death or circulatory death, with protocols in place to confirm death and obtain consent before organ retrieval. The recognition of brain death, though not yet codified in a standalone law, is operationally accepted under national medical guidelines. Medical personnel from the transplant clinic are not permitted to participate in the determination of death. Living donation is permitted only for individuals who can demonstrate a familial relationship with the donor, including the donor's spouse, direct relatives and blood relatives up to the third degree of collateral kinship. It is subject to rigorous medical, psychological, and ethical evaluation.

Organ allocation and transplantation are managed through COTRS, which uses a standardized algorithm to match donors and recipients based on medical urgency, compatibility, and waiting time. Pediatric recipients receive prioritized access to organs from pediatric donors, reflecting policy efforts to protect vulnerable populations. Transplant centers must be licensed and are subject to regular audits and performance evaluations. The regulatory framework also mandates post‐transplant follow‐up and data reporting to monitor outcomes and ensure continuous quality improvement. Together, these mechanisms form a comprehensive system designed to uphold ethical standards, optimize resource use, and promote public trust in organ transplantation.

3. Organ Allocation Policy for Pediatric Transplantation

Since August 2018, China has implemented a revised national organ allocation policy that prioritizes pediatric recipients, particularly in kidney and liver transplantation [11]. This initiative, led by the NHC, is grounded in the 2018 Basic Principles and Core Policies for China Organ Allocation and Sharing, which formally integrated pediatric prioritization into the national framework [12]. The policy recognizes the adverse effects of organ failure on children's growth and development, mandating that organs from donors under 18 years of age be preferentially allocated to recipients of the same age group. To support this reform, the China Organ Transplant Response System (COTRS) Version 2.0 was launched in October 2018. Allocation principles differ by organ type (Table 1) [12].

TABLE 1.

Pediatric organ allocation rules in China (by organ).

	Liver [12]	Kidney [12]	Heart [12]	Lung [12]
Definition of pediatric recipient	< 18 years (PELD < 12 years; MELD ≥ 12 years)	< 18 years	< 18 years	< 18 years
Primary pediatric priority rule	Pediatric donor livers (< 12 years) prioritized for pediatric recipients (< 12 years)	Pediatric recipients (< 18 years) receive priority in matching score	Pediatric donor hearts (< 18 years) prioritized for pediatric recipients (< 18 years)	Age‐matched allocation: child lungs to children, adolescent lungs to adolescents
Urgency scoring system	PELD (< 12 years), MELD (≥ 12 years), plus pediatric super‐emergency criteria	Waiting‐time–based score with pediatric priority modifier	Pediatric emergency vs. general status	Emergency/general status (< 12 years); LAS (≥ 12 years)
Pediatric super‐emergency criteria	Acute liver failure, graft non‐function, HAT, metabolic diseases, severe decompensation	Not defined as “super‐emergency”	Defined for minors: ventilation, ECMO, severe PH, growth failure, age < 6 months	Defined for < 12 years.: respiratory failure, ventilation, ECMO
Age‐matching rules	< 12 donor → < 12 recipient	Donor age stratified: < 2 years. → < 5 years.; 2–7 years. → < 14 years.; 7–18 years. → < 18 years	< 18 donor → < 18 recipient	< 12 donor → < 12 recipient; 12–18 donor → 12–18 recipient
ABO‐Incompatible Transplantation	Allowed only for super‐emergency or MELD/PELD ≥ 30	Not permitted	Permitted in limited pediatric emergency cases (e.g., < 1 year., low titers)	Not permitted
Special Pediatric Indications	Metabolic diseases, primary hyperoxaluria, pediatric HCC, urea cycle disorders	Growth impairment considered in priority	Congenital heart disease, growth failure	Pediatric respiratory failure syndromes
Waiting Time Calculation	Adjusted by urgency score dwell time	Calculated from listing (children) or dialysis start (adults)	Combined urgency‐level dwell time	Emergency time weighted for < 12 years
Policy Rationale	Reduce pediatric mortality and size mismatch	Minimize growth impairment from dialysis	Prevent irreversible developmental damage	Optimize survival and size compatibility
Definition of Pediatric Recipient	< 18 years (PELD < 12 years.; MELD ≥ 12 years)	< 18 years	< 18 years	< 18 years

Liver transplantation utilizes the Pediatric End‐Stage Liver Disease (PELD) scoring system for children under 12 years, with scores stratified as ≥ 25, 19–24, 11–18, and ≤ 10 points, corresponding to validity periods of 14 days, 1 month, 3 months, and 12 months respectively. Children under 18 years may be classified in super emergency status. Livers from donors under 12 years are preferentially allocated to recipients under 12 years to ensure size‐appropriate matching.

Kidney transplantation employs a composite scoring system that includes a pediatric priority component. Age‐stratified allocation follows three tiers: kidneys from donors under 2 years prioritize recipients under 5 years; kidneys from donors aged 2–6 years prioritize recipients under 14 years; and kidneys from donors aged 7–17 years prioritize all recipients under 18 years.

Heart transplantation reserves hearts from donors under 18 years for pediatric recipients. Emergency status criteria include ventilator or mechanical circulatory support, reactive pulmonary hypertension in infants under 6 months, refractory arrhythmias with life expectancy under 2 weeks, and growth failure below the 3rd percentile. All infants under 6 months automatically qualify for emergency status. ABO‐incompatible transplantation is permitted for infants under 1 year in emergency status and for select older children with low isoagglutinin titers.

Lung transplantation uses a bifurcated approach: children under 12 years are classified by categorical medical urgency (emergency versus general status based on respiratory failure parameters and need for ventilator or ECMO support), while adolescents 12 years and older use the Lung Allocation Score. Lungs from pediatric donors (under 12 years) are prioritized to pediatric recipients, and lungs from adolescent donors (12–17 years) to adolescent recipients.

The legal framework strictly prohibits living organ donation from individuals under 18, reinforcing the protection of minors [10, 13].

In summary, the policy explicitly prioritizes pediatric donor organs for pediatric recipients to improve clinical outcomes and long‐term survival, which aligns with other international frameworks, such as the OPTN in the USA and Eurotransplant in Europe (Table 2). Age‐matching between donor and recipient is a core allocation principle and children receive priority independent of waiting time when urgency or developmental risk is high. Further, China's system formally recognizes growth failure and metabolic diseases as pediatric‐specific indications. Through updated legal provisions, a centralized computerized allocation platform, and ethical safeguards, the framework promotes fairness, transparency, and clinical efficacy in organ sharing, with a distinct emphasis on improving access and outcomes for children.

TABLE 2.

Comparison of pediatric organ allocation systems in China, USA (OPTN) and Europe (Eurotransplant).

	China [12]	USA (OPTN) [14]	Eurotransplant (ET) [15]
Liver	Pediatric priority and age‐matching are built into allocation; scoring through PELD (< 12 years) and MELD (≥ 12 years), with pediatric high‐urgency pathways. PELD special exception scores available for childhood metabolic diseases. Livers from donors under 12 years are prioritized to recipients under 12 years	Uses PELD (< 12) and MELD (≥ 12); Status 1A and Status 1B provide priority for very sick pediatric candidates under 18 years and are exceptions to MELD/PELD. PELD special scores available for specific pediatric conditions including childhood metabolic diseases	Pediatric patients < 18 years automatically receive initial pediatric MELD (35% for < 12 years, 15% for 12–17 years) with automatic 90‐day upgrades. Pediatric MELD freezes at level reached when turning 18; Germany removes all pediatric points at age 18 for national allocation
Kidney	Waiting time for children (< 18 years) begins at the time of joining the waiting list. Explicit age‐stratified allocation (pediatric donor kidneys preferentially to pediatric recipients). Pediatric candidates receive priority points in the composite scoring system	Pediatric priority is incorporated into the allocation scoring system, but primarily applies to higher‐quality kidneys (KDPI < 35%); candidates under 18 receive priority points in the composite scoring system	ETKAS pediatric bonus: Pediatric patients < 18 years receive 100 bonus points and double HLA mismatch points; bonus gradually phases out from age 18–30. Donors < 18 years are allocated first to pediatric patients, then adults
Heart	Pediatric donor hearts are prioritized for pediatric recipients. Specific pediatric urgency criteria exist; all infants under 6 months automatically qualify for emergency status. ABO‐incompatible heart transplantation permitted for infants < 1 year in emergency status	Pediatric heart allocation uses pediatric status tiers; Hearts from donors under 18 years are prioritized to pediatric recipients under 18 years; ABO‐incompatible (ABOi) heart transplantation is permitted for candidates registered before turning 18	All pediatric patients (< 16 years or still growing with proof) automatically receive international High Urgency status. Hospitalized pediatric patients have priority over adult HU patients; proof of maturation via X‐ray of left hand valid for 1 year. ABO‐incompatible heart transplants are only allowed in patients under the age of 2 years
Lung	Children under 12 years use categorical medical urgency (emergency vs. general status), adolescents ≥ 12 years use Lung Allocation Score (LAS) like adults. Lungs from pediatric donors (< 12 years) prioritized to pediatric recipients; lungs from adolescent donors (12–17 years) prioritized to adolescent recipients. No ABO‐incompatible lung transplantation permitted	Candidates under 12 years use categorical medical urgency classification (Priority 1 and 2) rather than Lung Allocation Score (LAS); candidates ≥ 12 years use LAS like adults. Lungs from pediatric donors (< 12 years) are prioritized to pediatric candidates; lungs from adolescent donors (12–17 years) are prioritized to adolescent candidates; ABOi lung transplantation permitted for candidates registered before turning 18	ET thoracic allocation applies urgency‐based principles. All pediatric patients < 12 years automatically receive LAS of 100. Lungs from donors < 12 years allocated first to recipients < 12 years, then 12–17 years, then ≥ 18 years

4. Methods

4.1. Data Source

This retrospective study analyzed publicly available data from the Report on Organ Donation and Transplantation in China (RODTC) between January 2015 and December 2024 [11, 16, 17, 18, 19, 20, 21]. Pediatric patients were defined as aged < 18 years.

4.2. Software

All data analyses and visualizations were conducted using Python (3.11) with the pandas, matplotlib and numpy libraries.

5. National Statistics on Pediatric Transplantation

5.1. Overview

The annual trends for pediatric transplants by organ are shown in Figure 1. From 2015 to 2024, an increase of pediatric transplantation is observed for kidney (4.9‐fold), liver (2.1‐fold) and lung (7.5‐fold). As the heart allocation system in COTRS was established at the end of 2018, prior data are not included in the RODTC. From 2019 to 2024, the number of pediatric heart transplants has increased 2.5‐fold. While the proportion of kidneys and hearts transplanted to children has increased too, such a trend is not observed for liver and lung transplantation (Figure 2).

FIGURE 1.

Number of pediatric organ transplantation cases in China from 2015 to 2024 by organ. The Y‐axis indicates the annual number of transplantation cases; the X‐axis indicates the year. Heart transplant data are available from 2019 to 2024 after implementation of the heart allocation system in COTRS at the end of 2018.

FIGURE 2.

Annual trends in pediatric organ transplantation in China (2015–2024). Each panel shows the proportion of pediatric cases among total liver, kidney, heart, and lung transplants. Bars indicate yearly transplant volumes, with colored segments for pediatric and gray for adult cases. Pediatric heart transplant data are shown from 2019 onward, following the implementation of the heart allocation system in COTRS in late 2018.

During 2015–2018 child donors accounted for 11.40% of deceased donors. In 2019, there were 477 child donors (8.20%).

In 2022, 63.6% of livers donated to children were from living‐related donors. The majority of kidney transplants were from deceased donors (93.3%), with 88.0% being child donors. Data on the cause of death and other demographics of the donors are not detailed in the national reports.

5.2. Transplantation Centers

As of 2025, there were 187 hospitals qualified for organ transplantation in China including Liver (117), Kidney (158), Heart (58), Lung (36), Pancreas (33), and Small Intestine (24) [10]. Most transplant activity and qualified hospitals are concentrated in major eastern provinces and top‐tier cities, while central and western regions have far fewer resources and lower transplant volumes. Organs are primarily allocated within the same province, not across regions [12].

Of the 15 pediatric lung transplants in 2024, 11 were performed at the Second Affiliated Hospital Zhejiang University School of Medicine, 2 at the First Affiliated Hospital of Guangzhou Medical University, and 1 each at the Wuxi People's Hospital and the First Affiliated Hospital of University of Science and Technology of China. For the other organs, no national data are published regarding the number of medical centers performing pediatric transplantation.

The three most active pediatric kidney transplantation centers were Children's Hospital of Fudan University, Shanghai, the First Affiliated Hospital of Sun Yat‐sen University, Guangzhou, and the First Affiliated Hospital of Zhengzhou University [22]. These centers account for a third of all pediatric kidney transplantations in China.

Major centers for pediatric liver transplantation are the Renji Hospital in Shanghai and the Tianjin First Central Hospital [23, 24]. The Fuwai Hospital in Beijing performs the highest number of heart transplantations overall and also has the highest pediatric cardiac surgical volume [25].

5.3. Pediatric Indications for Organ Transplantation

In 2024, the main causes for pediatric heart and lung failure with consecutive transplantation are shown in Figure 3A,B. Non‐ischemic cardiomyopathy was the leading cause of pediatric heart recipients, accounting for 77.0% of heart transplants, followed by congenital heart disease (15.2%). For lung transplantation recipients, bronchiolitis obliterans was the main cause (59.1%), followed by secondary pulmonary hypertension and primary pulmonary hypertension (both at 13.3%).

FIGURE 3.

Most common primary diseases in pediatric heart, lung, liver and kidney transplant patients in China. The pie charts show the proportion of each indication for heart (A), lung (B), liver (C) and kidney (D) transplantation among pediatric patients. Data sources vary by organ: Heart (A) and lung (B) transplantation from national data (2024); liver (C) transplantation from Renji Hospital (2006–2022); kidney (D) transplantation from a multicenter cohort including Children's Hospital of Fudan University (in cooperation with Changhai Hospital, Shanghai Center), The First Affiliated Hospital of Sun Yat‐sen University (Guangzhou Center), and The First Affiliated Hospital of Zhengzhou University (Zhengzhou Center) (2011–2018).

While the RODTC does not detail the primary diseases in pediatric kidney and liver transplant recipients, the Renji Hospital in Shanghai, which performs the highest number of liver transplants, describes cholestatic liver disease, especially biliary atresia, and metabolic liver disease as the most frequent indications for pediatric liver transplantation (Figure 3C) [23]. An analysis from three centers located in Shanghai, Guangzhou, and Zhengzhou, which have the greatest number of pediatric kidney transplantation cases in China, showed that glomerulonephritis (16.4%) and steroid‐resistant nephrotic syndrome (14.7%) were most common known primary diseases (Figure 3D) [22]. However, in 53.3% of the patients, the cause of renal failure remained unknown and this study included 18 year old patients as well as data from 2011 to 2018.

5.4. Outcomes

For heart transplantation, both adults and children achieved high early survival, with 30‐day survival rates of 91.7% and 94.7%, respectively (Table 3). Children showed a modest advantage across all time points. Both adult and pediatric 30‐day and 1‐year survival rate consistently remained above 80%. Survival rates at 3 years (75.0% in children vs. 74.2% in adults) and 5 years (70.0% vs. 69.1%) were similar between the two groups, although slightly higher in children.

TABLE 3.

Comparison of survival rates post‐operation of heart, lung, kidney, and liver transplantation between adult and pediatric recipients among different data sources.

Organ	Age group	30‐day survival rate (%)	3‐month survival rate (%)	6‐month survival rate (%)	1‐year survival rate (%)	3‐year survival rate (%)	5‐year survival rate (%)	10‐year survival rate (%)	Data source
Heart	Adult	91.7	—	—	80.1	74.2	69.1	—	RODTC (2015–2024) [12]
	Pediatric	94.7	—	—	87.6	75.0	70.0	—
Lung	Adult	84.0	74.1	67.6	60.1	45.7	—	—
	Pediatric	91.0	81.8	79.2	79.2	64.9	—	—
Kidney	All age	—	—	—	97.7	96.2	94.6	—	RODTC (2015–2024) [12]
	Pediatric	—	—	—	97.6	—	95.5	—	Multicenter cohort (2011–2018) [22]
Liver	All age	—	—	—	84.2	74.0	66.8	—	RODTC (2015–2024) [12]
	Pediatric	—	—	—	95.1	—	93.1	91.8	Single‐center cohort (2006–2022) [26]

For lung transplantation, children demonstrated higher early survival rate, reaching a 30‐day survival rate of 91.0% compared with 84.0% in adults (Table 3). Pediatric survival rate remained above 79% after 3 months, 6 months, and 1‐year of lung transplantation, whereas adult 1‐year survival rate declined to 60.1%. The 3‐year survival rate after lung transplantation was higher in pediatric patients (64.9%) than in adult patients (45.7%).

National‐level data for the pediatric cohort are not reported on graft and patient survival after kidney or liver transplantation in the pediatric cohort, while the RODTC provide overall postoperative survival outcomes in the general transplant population. For kidney transplantation, the aforementioned multicenter study on Chinese pediatric kidney transplantation showed 1‐ and 5‐year patient survival rates of 97.6% and 95.5%, respectively [22, 27], which were comparable to the overall survival rates of 97.7% and 94.6% [11]. For liver transplantation, a large single‐center retrospective cohort study of pediatric liver transplantation in China reported consistently favorable long‐term patient survival, with 1‐, 5‐, and 10‐year survival rates all exceeding 90% [26], whereas the overall survival rate was 84.2% at 1‐year after liver transplantation and decreased to 66.8% at 5 years (Table 3) [11].

6. Quality Control Measures

China has established four comprehensive registries to perform lifelong follow‐up for transplant recipients. These include the China Scientific Kidney Transplant Registry, China Liver Transplant Registry, China Heart Transplant Registry, and China Lung Transplant Registry [17]. These registries enable rigorous tracking of patient outcomes and contribute to the generation of survival rates.

The registries are cross‐checked with national databases, such as the national death registry, to identify cases of patient mortality that may not be captured otherwise. This integration of registry and national data strengthens the accuracy of survival statistics and provides a robust framework for quality control across all transplant programs. Each registry also serves as a scientific platform to advance surgical techniques, improve post‐transplant outcomes, and support national quality control centers through large‐scale data collection and analysis—thereby fostering evidence‐based improvements in clinical practice and transplant care across China [28].

7. Discussion and Future Outlook

Organ transplantation in China has progressed substantially. Nonetheless, with 16.67 organs transplanted per million population in 2023, the number is still lower than the global average (25.84), the USA (139.68), Germany (43.77) or Japan (20.64) [9]. As there is a significant association between number of transplantations and gross national income per capita [29], it is expected that the upwards trend of transplant activity in China will continue.

International legislation on the prioritization of children in organ allocation is heterogenous. In line with the ethical principles of the United Network for Organ Sharing (UNOS) [30] and similar to Eurotransplant's policy [31], pediatric patients are also prioritized in the Chinese organ allocation system. Post‐implementation data indicate a marked increase in pediatric transplant rates since the revision of the organ allocation policy in 2018. Comparative analysis reveals that in 2024, 34.40% of children on the kidney transplant waiting list received organ allocations, compared to only 7.46% of adults [12]. This represents a 4.6‐fold higher allocation rate for pediatric patients, underscoring the policy's effectiveness in enhancing access to donor kidneys for children. This has catalyzed significant advancements in pediatric transplantation, particularly for liver and kidney grafts, supported by the development of age‐specific surgical protocols and tailored immunosuppressive regimens.

The data shown were retrieved from the Report on Organ Transplantation Development in China, compiled by the China Organ Transplantation Development Foundation. While the reports describe overall statistics extensively, several gaps persist regarding pediatric transplantation, such as the demographics of donors and recipients, indications for organ transplantation, graft and patient survival for kidney and liver, number of medical centers performing pediatric transplantation. Future studies are necessary to close these gaps.

China has undertaken initiatives to enhance organ transplantation cooperation with Hong Kong and Macao, reflecting a broader commitment to regional medical integration. In 2017, Macao was integrated into the Chinese national organ allocation and sharing system, aiming to increase organ supply and benefit local patients [32]. A landmark cross‐boundary heart transplant in 2022 marked the first successful organ donation via COTRS from the Chinese Mainland to Hong Kong, demonstrating the feasibility of interjurisdictional collaboration [33]. Subsequent high‐level discussions in 2023 between Hong Kong's Health Bureau and the National Health Commission signaled intent to institutionalize such exchanges, though legal and regulatory barriers remain. Mutual organ sharing between Hong Kong and Taiwan has been reported [34, 35]. China's updated national regulations on organ donation and transplantation, issued in December 2023, aim to standardize practices and may facilitate future cross‐regional coordination. The regulation also mandates the public release of data on organ donation and allocation, thereby facilitating the closure of previously noted gaps.

Despite substantial regulatory progress and system‐level improvements, several limitations remain, particularly in the field of pediatric organ transplantation. Pediatric transplantation represents a comparatively small proportion of overall transplant activity and faces inherent challenges related to limited donor availability, size‐matching constraints, and the need for highly specialized multidisciplinary expertise. These factors may lead to regional disparities in access to pediatric transplant services and concentrate procedures in a limited number of high‐volume centers. In addition, long‐term outcome data and pediatric‐specific clinical benchmarks remain less extensively documented than in adult transplantation. Continued efforts to strengthen national registries, expand pediatric training capacity, and further standardize clinical protocols will be essential to ensure equitable access and sustained quality improvements for pediatric transplant recipients within China's evolving transplantation system.

8. Conclusion

Pediatric organ transplantation in China has entered a stage of steady expansion and structural maturity, supported by comprehensive legal regulation, centralized allocation systems, and a strong commitment to ethical transparency. The implementation of the 2018 pediatric prioritization policy and the continuous refinement of the China Organ Transplant Response System (COTRS) have markedly improved access and outcomes for children with end‐stage organ failure. Nevertheless, key challenges persist, including limited data on long‐term graft survival, uneven regional distribution of transplant resources, and the ongoing shortage of pediatric donors. Strengthening national registries, promoting multicenter collaboration, and investing in pediatric‐specific training and infrastructure will be vital to closing these gaps. As China continues to align its practices with international ethical and clinical standards, sustained efforts toward data visibility in peer‐review publications and cross‐regional cooperation—particularly with Hong Kong, Macao, and potentially Taiwan—will further enhance the quality, equity, and sustainability of pediatric transplantation nationwide.

Author Contributions

B.N. and H.W. conceptualized the review. A.L. and C.S. performed data acquisition and analysis, literature search, prepared figures and tables and contributed to writing. All authors contributed to data interpretation and manuscript revision. All authors have read the manuscript and approved of its submission.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are openly available in the Reports on Organ Transplantation Development China.