Organ transplantation, particularly pediatric liver transplantation (LT), has transformed medical practice over the past six decades, providing life-saving interventions for children with end-stage liver disease. This review demonstrated the historical milestones of pediatric organ transplantation, emphasizing Japan's contributions, mainly through the National Center for Child Health and Development. While early transplantation efforts in the 1950s and 1960s faced significant challenges, breakthroughs in preservation methods, immunosuppressive therapies, surgical techniques, and innovations such as living donor LT in Asia have greatly improved success rates. Japan's pediatric LT landscape is distinct, primarily due to its reliance on living donor LT, shaped by cultural and religious influences that have traditionally restricted deceased donor organ donation. This review manuscript discusses Japan's pioneering role in expanding the indications for pediatric LT to include rare conditions such as inherited metabolic disorders and hepatoblastoma. It highlights recent innovations such as hyper-reduced lateral segment grafts, machine perfusion, and minimally invasive surgery that have further improved outcomes. International collaboration has facilitated the sharing of expertise, advancing pediatric liver transplantation practice worldwide. Despite these achievements, challenges remain, particularly in light of Japan's declining birth rate, which threatens the sustainability of pediatric transplant services. This review emphasizes the need for centralized transplant facilities, greater awareness of brain-dead organ donation, and continued medical advances to ensure that pediatric LT remains a viable, life-saving option for future generations.
Humans ; Liver Transplantation/trends* ; Japan ; Child ; Living Donors

Pediatric organ transplantation has evolved significantly since the 1950s, with breakthroughs in immunosuppressive therapy in the 1980s. Worldwide, around 2,700 pediatric liver transplants are performed annually, with living donor transplants dominating in Japan due to cultural and legal limitations surrounding brain-dead organ donation. Regional disparities in transplant practices are evident, with braindead transplants being more common in North America and Europe, while living donor transplants prevail in Asia and the Middle East. Technological innovations such as machine perfusion and minimally invasive surgery have enhanced transplant outcomes and addressed the ongoing donor shortage. Despite excellent long-term survival rates, challenges persist, particularly with graft fibrosis, which affects over 60% of pediatric recipients within a decade post-transplant. A critical issue is the transition of pediatric transplant patients to adult care facilities, where nonadherence with immunosuppressive regimens is associated with a high mortality rate. As the number of pediatric transplant cases rises, the need for increased human and financial support becomes more pressing to ensure these patients receive comprehensive care throughout their lives.