Development of multicenter consensus care plans for immunosuppression after pediatric liver transplant: Reducing variability, creating comparative efficacy opportunities

Post-transplant immunosuppression (IS) significantly impacts patient and graft outcomes. The Starzl Network for Excellence in Pediatric Transplantation (SNEPT), a multicenter learning health network dedicated to pediatric liver transplant, identified IS optimization as a priority project. Here we describe SNEPT’s development of consensus care plans (CCPs) for induction IS after pediatric liver transplantation, using an adapted nominal group technique to achieve consensus. First, 16 SNEPT transplant centers across the U.S. and Canada shared individual center IS protocols. Collation of center-specific protocols identified five key medications (basiliximab, thymoglobulin, corticosteroids, mycophenolate mofetil, and tacrolimus). Dosing consensus and variability across all 16 center protocols were summarized by SNEPT’s Optimizing IS working group. Through iterative cycles of feedback conducted in-person and virtually, 2022-2025, CCPs for each medication were developed, reviewed with stakeholders and revised. CCPs were finalized with consensus from all 16 centers. CCPs were presented at SNEPT’s network-wide meeting as well as at individual center multidisciplinary meetings to assess accuracy of captured current practice and agreement with implementation. CCPs were finalized with universal network consensus and will be implemented across the network, laying foundational work for prospective quality improvement and comparative effectiveness studies.