Liver allocation

Abstract

Liver allocation policies determine how those livers that are offered for transplantation are allocated to those who have met the criteria for liver transplantation and are fit enough to undergo the procedure. The goals of allocation policies are based on varying combinations of need (reducing mortality awaiting a graft), benefit (maximizing the outcomes of candidates on the list) or utility (maximizing the life-years gained). Improvement in quality of life is rarely included in the setting of allocation policies. Policies need to be complaint with legal and ethical standards, ensure equity, and provide transparency. Most jurisdictions have used two major categories: high-urgency (such as acute liver failure) and elective where candidates are ranked according to need. Need for these candidates is often measured by the MELD score (or its modifications): although there are many valid concerns about the model, it remains the most widely used. Some jurisdictions are developing models which allocate on the basis of transplant benefit. It is important that allocation models do not stifle innovation and research. Different jurisdictions have developed different approaches to respond to the variations in both donors and recipients, the geographical challenges, prevalence of liver disease and donor rates and how to include those whose prognosis is not assessed by the standard models. While there is a need to review and audit policies regularly, and revise if necessary, development of the ideal policy should not distract from approaches to increase donor rates, maximise the quality of offered organs and ensure all useable organs are indeed used.