Moving toward the utilization of all donated liver grafts. The "b-list" concept

Abstract

The number of available liver grafts is not sufficient to meet the current demand. A significant number of patients succumb before they receive a liver graft. However, approximately 10% of marginal livers are considered unsuitable for donation and are discarded. Calculating the primary non-function probability for any given liver graft can be performed using prognostic tools, such as the Donor Risk Index and the Eurotransplant Donor Risk Index. On the other hand, mortality on the waiting list, which is sometimes more than 15% per year of enlistment, directly correlates with its size, the graft supply and the gravity of the potential recipients' clinical condition. Up to 30% of the potential recipients will never receive a graft. The purpose of this invited commentary is to examine whether the literature supports the utilization of the marginal liver grafts that would otherwise be discarded. It appears that there is sufficient evidence in favor of the development of a "B-list" for potential liver graft recipients. It should comprise all of the candidates who were definitely removed from the primary waiting list or were never included. The potential "B-list" recipients should only be eligible to receive grafts that would otherwise be discarded, i.e., "B-livers". Enrollment in a "B-list" might not only increase the overall patient survival (enlisted and transplanted combined) but might also improve candidate quality of life by maintaining their hope for a cure.

Keywords: Liver transplantation; equity; marginal grafts; organ allocation; utility; waiting list.

Figure 1. The relative risk (RR) of death after liver transplantation with a low-quality graft (DRI > 1.65) compared to no transplantation, stratified according to patient MELD score. Liver transplantation with low-quality grafts is beneficial only when the recipient MELD score exceeds 20 (RR = 0.52). The RR for patients with MELD scores between 15 and 19 ranges from 0.65 to 0.83, but the 95% confidence intervals (CI) include 1.0 (CI not depicted for simplicity of the diagram). OLTx: Orthotopic Liver Transplantation.