Regional variations and trends in liver transplantation practices across Europe

Abstract

Background & aims: Liver transplantation (LT) is a live-saving therapy for patients with end-stage liver disease, but demand exceeds supply, leading to waiting list (WL) mortality. This study reviews LT practices and trends in Europe to identify potential policies for improving outcomes.

Methods: Data were extracted from the European Liver Transplant Registry and the Global Observatory on Donation and Transplantation. Countries were categorized into Eastern (EEC), Mediterranean (MEC), and Northern European (NEC). We analyzed LT indications, recipient and donor age, transplant type, and WL outcomes from 2012 to 2022.

Results: Etiology of LT differed across regions: HBV cirrhosis predominated in EEC (37.3%), whereas alcohol-related liver disease was more frequent in NEC (41.8%) and MEC (49.1%). Metabolic-dysfunction associated steatotic liver disease increased across Europe, particularly in NEC. Recipient age has risen, with 40% aged ≥60 years in MEC vs. 20% in EEC. Donor age and type also varied: EEC relies on younger donors (<50 years, 70%), whereas MEC expanded criteria to include donors ≥60 years (50%). Donation after circulatory determination of death increased by 30%, particularly in NEC and MEC, but remains rare in EEC. Model for end-stage liver disease scores at LT decreased, with 30% scoring >21 in 2021 vs. 50% in 2012. WL mortality declined by 10% since 2015, although large inter-country variability persists.

Conclusions: LT practices in Europe are highly heterogeneous. Regional disparities in recipient profiles, donor characteristics, and transplant modalities reflect varying policies and healthcare capacities. Expanding donor criteria and harmonizing allocation systems are required to reduce WL mortality and improve access to LT across Europe.

Impact and implications: This study provides a comprehensive analysis of liver transplantation practices across Europe, highlighting significant regional disparities in donor criteria, allocation systems, and transplant outcomes. By identifying trends such as the expansion of Donation after Circulatory Determination of Death programs and the prioritization of model for end-stage liver disease ≥30 policies, these findings underscore the critical need for harmonized strategies to reduce waiting list mortality and improve access to transplantation. The results are particularly relevant for policymakers and healthcare administrators seeking to optimize liver transplant systems, and for clinicians aiming to adopt best practices from high-performing regions. Practical applications include refining allocation policies, expanding donor pools, and addressing regional inequalities, all while considering the limitations posed by diverse healthcare infrastructures and socioeconomic factors.

Keywords: Alcohol-related liver disease; Metabolically associated steatohepatitis; Organ allocation; Waiting list mortality.

Graphical abstract

Fig. 1

Trends in liver transplant activity in Main European countries. The figure displays the number of patients per million for three key metrics: newly included on the waiting list (blue line), liver transplants performed (green line), and mortality on the waiting list (red line), across European countries. Trends visualized using locally weighted scatterplot smoothing (LOWESS).

Fig. 2

Evolution of donor age distribution in Europe. The figure displays the age distribution of liver donors over time in Northern, Mediterranean, and Eastern Europe, and the overall trend in Europe. The age groups range from 0–20 to >70 years, showing changes in the reliance on younger vs. older donors across regions. Descriptive data displayed as stacked bar charts of donor age distribution over time.

Fig. 3

Evolution of liver transplant recipient age distribution in Europe. The figure illustrates the age distribution of liver transplant recipients over time in Northern, Mediterranean, and Eastern Europe, and overall trends across Europe. The age groups range from 0–2 to >70 years, highlighting changes in the recipient demographics over the last decade. Descriptive data displayed as stacked bar charts of recipient age distribution over time.

Fig. 4

Evolution of liver transplant indications across Europe. The figure shows the changes in the etiologies leading to liver transplantation over time in North-Central, Mediterranean, and Eastern Europe, and overall trends across Europe. Etiologies include alcohol-related liver disease (ETOH cirrhosis), Hepatitis B (HBV) cirrhosis, Hepatitis C (HCV) cirrhosis, metabolic-dysfunction steatotic liver disease (NASH), and other causes. Descriptive data displayed as stacked bar charts of liver transplant indications over time.

Fig. 5

Evolution of biochemical MELD score distribution in Europe. The figure illustrates the changes in the distribution of MELD scores among liver transplant recipients over time across Northern, Mediterranean, and Eastern Europe, and Europe overall. MELD score categories are shown, ranging from 0–14 to >30, highlighting the shift towards lower MELD scores over the last decade. Descriptive data displayed as stacked bar charts of MELD score distribution over time.

Fig. 6

Global burden of mortality in the waiting list and from liver disease in large volume countries. The figure shows the trends in overall mortality rates from liver disease and mortality rates on the waiting list for liver transplantation in large volume countries (France, Germany, Italy, Spain, and the UK). The blue line represents the overall mortality rate, while the red line represents the mortality rate in the waiting list over time. Trends visualized using locally weighted scatterplot smoothing (LOWESS).