Improving access for liver allocation

Making liver distribution more fair and equitable 

About policy development

In its role as the Organ Procurement and Transplantation Network (OPTN), UNOS convenes the donation and transplant community to develop policies that provide fair and equitable access for patients to transplant. Many times during the past 30 years, these policies have been updated by the OPTN Board of Directors to balance the needs of patients nationwide and keep pace with the emerging science of transplantation.

Reducing disparities

For years, the system that matches donated livers with patients who need them was based on the inconsistent geographic boundaries of 57 donation service areas (DSAs) and 11 transplant regions. These areas of distribution vary widely in size, population density and concentration of donor and transplant hospitals. Over time, great disparities have developed in how sick liver candidates need to become in various parts of the country before they are likely to receive a transplant.

In its role as the OPTN, UNOS has been working for more than five years on a system to replace these inconsistent boundaries with a system that appropriately balances candidates’ medical urgency with the relative distance from their transplant hospital to a donor hospital.

New policy saves more lives

In December 2018, the OPTN board approved a new allocation system for liver transplantation. It is projected to save more lives annually, with fewer patients dying while waiting for a liver transplant. It also is expected to increase the number of pediatric liver transplants, making this a policy that will work more efficiently and fairly for patients across the entire country. The policy was developed by donation and transplant experts, recipients and donor families from around the country, with consideration of thousands of public comments.

Modeling shows that under the new system:

• Fewer people will die waiting
• More children will receive a transplant
• The geographic location of patients will be less important than how sick they are

How does it work?

DSA and regional boundaries were replaced by a sequence of circles in which we compare candidates’ degree of illness and the distance between donor hospital and their transplant hospital. It first prioritizes the very sickest liver candidates (Status 1A and 1B) listed at transplant hospitals within 500 nautical miles of the donor hospital. Following that, it prioritizes candidates of similar groupings of medical urgency—first those within 150 nautical miles, then those within 250 and 500 nautical miles.

Livers from deceased donors younger than age 18 are first offered to any candidates younger than age 18, listed at any transplant hospital within a 500 nautical-mile radius of the donor hospital, before any adult candidates of the same level of medical urgency.