Pediatric lung transplantation in Japan across legislative and allocation reforms: A nationwide registry analysis of waitlist and post-transplant outcomes

Background Pediatric lung transplantation is a life-saving option for end-stage lung disease, but national data from Japan, particularly regarding the impact of recent policy changes, are limited. Methods Nationwide registries of candidates (deceased-donor waitlist) and recipients in Japan (1998–2024) were analyzed with follow-up through July 2025. Outcomes were evaluated across three eras defined by the 2010 legislative revision and the 2020 pediatric priority rules. Waitlist outcomes were assessed within 2 years of listing and post-transplant survival within 2 years of transplantation (administrative censoring at 730 days) to support fair era comparisons. Results Among 2732 candidates, 149 (5.5%) were children. Within 2 years of listing, pediatric candidates were more likely to undergo lung transplantation than adults (35.6% vs 18.2%) and less likely to die on the waitlist (13.4% vs 29.7%). The proportion transplanted within 2 years increased from 9.4% in 1998–2009 to 38.2% in 2010–2019 and 49.0% in 2020–2024, while 2-year waitlist death decreased from 21.9% to 13.2% and 8.2%. At 2 years after transplantation, survival was 86.0% in pediatric recipients and 81.8% in adults; pediatric recipient status remained independently associated with lower mortality (aHR 0.47, 95% CI 0.32–0.71; p < 0.001). Descriptive Kaplan–Meier curves up to 10 years suggested favorable longer-term survival, with broadly comparable outcomes after pediatric living-donor and deceased-donor transplantation. Conclusions Pediatric lung transplantation in Japan remains numerically limited but has substantially benefited from legislative and allocation reforms, with improved access to transplantation and reduced waitlist mortality. These findings provide a current national reference for pediatric lung transplantation in a donor-limited setting.