Making liver distribution fair for all
New national liver transplant system makes allocation more equitable and saves more lives
The new liver distribution policy was designed to make the system work more efficiently and fairly for all transplant patients regardless of where they live, what hospital they choose for their care, or how sick they must be before they are likely to get a transplant.
Adopted by the Organ Procurement and Transplantation Network (OPTN) Board of Directors in December 2018, the policy was originally planned for implementation April 30, but has been rescheduled to begin May 14. It re-calibrates how geography is considered when matching donated livers with transplant recipients based on experience gained with the previous, decades-old system. That system has relied heavily on the arbitrary geographic boundaries of 58 donor service areas (DSAs) and 11 transplant regions.
The new system eliminates those map-based boundaries and corrects inequities that emerged over time within the old policy that led to unfair advantages and disadvantages based on where liver transplant recipients live.
Right now, where you live or where you choose to list for a transplant makes a huge difference in how sick you need to be before you get a liver transplant. This policy changes that, prioritizing the medical urgency of liver transplant candidates in relation to the distance between the donor hospital and transplant hospitals; the patients who are both most in need and closest to the donor will get offers first.
This transformative policy is the result of more than five years of work and was developed by transplant experts, organ recipients and donor families from around the country, with consideration of thousands of public comments.
“The transplant community shares the common goal of saving as many lives through transplantation as possible,” said Brian Shepard, UNOS Chief Executive Officer. “The new policy improves upon the previous system to make it fairer by providing more equitable access to a transplant for the benefit of all patients based on medical need. Over time the prior system developed geographic disparities and addressing these problems emerged as a top priority.”
In developing the new policy, the transplant community considered and modeled a number of options. The initial mandate to address geographic inequities in transplant access came from the board of directors in 2012, and the liver community has been working intensively on system improvements since 2014.
How will the system prioritize liver transplant candidates?
As in current liver distribution, livers from adult deceased donors first will be offered to a wide area for candidates in the most urgent (Status 1A and 1B) designations, because they are at great risk of imminent death without a transplant. At any given moment, there are generally fewer than 50 Status 1A and 1B candidates listed nationwide.
Under the new policy, livers from all deceased donors would be offered for compatible Status 1A and 1B candidates listed at transplant hospitals within a radius of 500 nautical miles of the donor hospital.
In the example here, transplant hospitals A, B and C all have Status 1A or 1B candidates compatible with the donor and are located within a 500 nautical-mile radius of the donor hospital.
After that, livers from deceased adult donors will be distributed in one of two ways depending on the donor’s age and mechanism of death. The examples below illustrate how the system will work based on different characteristics of the deceased donor.
“Donated organs are so very precious. We must do all things possible to distribute them as widely as possible so that they are utilized by the right patients at the right time to reduce the number of people who die waiting.”
Liver recipient, Woodlands, TX
Organ distribution for adult, non-DCD donors younger than age 70
The majority of deceased liver donors are adults who are under age 70 and who are not donating upon cardiorespiratory death (also known as DCD donation). For livers from these donors, after initial offers to Status 1A and 1B candidates as above, the next steps in distribution are as follows:
- candidates with a MELD or PELD score of 37 or higher listed at transplant hospitals within a radius of 150 nautical miles from the donor hospital
- candidates with a MELD or PELD score of 37 or higher listed at transplant hospitals within a radius of 250 nautical miles from the donor hospital
- candidates with a MELD or PELD score of 37 or higher listed at transplant hospitals within a radius of 500 nautical miles from the donor hospital
- a continuing sequence of progressive offers, from more local to more distant (at transplant hospitals within 150, 250 and 500 nautical miles of the donor hospital), for candidates with ranges of MELD or PELD scores from 33 to 36, from 29 to 32, and from 15 to 28
In this example:
- Transplant hospital A is within the 150 nautical-mile radius. Candidates at that hospital with a MELD or PELD of at least 37 would be first to receive compatible liver offers.
- The next candidates to receive offers are those who have a MELD or PELD of at least 37 and who are listed at hospitals C and D, both of which are within the 250 nautical-mile radius.
- Candidates with a MELD or PELD of at least 37 and listed at hospitals B, E and F would then receive offers, as they are beyond the 250 nautical-mile radius but are within 500 nautical miles.
- The sequence would continue to repeat for compatible candidates with progressively lower ranges of medical urgency. For example, the next group of candidates to receive offers would be those listed at Hospital A with a MELD or PELD between 33 and 36, followed by those at hospitals C and D with the same range of scores, then those at hospitals B, E and F with the same range of scores.
people died waiting for a liver transplant in 2018
“Cameron’s recipients were hours and days from dying, without his life saving organ they wouldn’t be here today! As donor families we choose to give life and want to see our loved ones’ precious gifts go to the people most in need wherever they are.”
Donor mother, Fargo, ND
Organ distribution for adult donors age 70 or older and/or DCD donors
For deceased donors older than age 70, and/or who die as a result of cardiorespiratory failure, the distribution sequence will provide earlier access for candidates more local to the donor hospital. Most livers from these donors are accepted for local candidates, since they are most viable when the preservation time between recovery and transplantation is brief.
For livers from these donors, after initial offers to Status 1A and 1B candidates as above, the initial distribution sequence is as follows:
- compatible candidates with a MELD or PELD of 15 or higher, listed at transplant hospitals within a 150 nautical-mile radius of the donor hospital
- compatible candidates with a MELD or PELD of 15 or higher, listed at transplant hospitals within a 250 nautical-mile radius of the donor hospital
- compatible candidates with a MELD or PELD of 15 or higher, listed at transplant hospitals within a 500 nautical-mile radius of the donor hospital
In this example:
- Offers would go to any compatible candidates with a MELD or PELD of at least 15 listed at Hospital A, which is within 150 nautical miles of the donor hospital.
- Next, offers would go to any compatible candidates with a MELD or PELD of at least 15 listed at Hospitals C or D (within a 250 nautical-mile radius).
- Offers would then go to candidates at Hospitals B, E or F (500 nautical-mile radius).
Donors prefer helping the sickest patients
The U.S. Department of Health and Human Services published the National Survey of Organ Donation Attitudes and Behavior in 2012.
Among respondents who had not granted permission for organ donation (on their driver’s license, a signed donor card, or by joining a state registry), most (81.7 percent) indicated that if they were donors, they would like their organs to be distributed to individuals with the most urgent medical need regardless of where they live in the U.S. Fewer (15.6 percent) indicated they would like their organs to be given to patients in their local area regardless of medical urgency.
Organ distribution for pediatric (younger than age 18) donors
For pediatric liver donors (younger than age 18), the proposed policy would increase priority for pediatric candidates before any adult candidates at the same level of medical urgency. Livers from pediatric donors would be offered initially to compatible pediatric candidates listed at any transplant hospital within a 500 nautical-mile radius of the donor hospital.
In this example, pediatric transplant candidates listed at transplant hospitals A, B or C would all be within the initial level of distribution for compatible donor offers.
“I was blessed to be transplanted earlier, rather than later. I believe that with the new policy, more lives will be saved with the sicker patients getting transplanted but the best part will be more children will get transplanted!”
Liver recipient, Rogers, AR
Exceptions for geographically isolated areas
Liver transplant programs located in Hawaii and Puerto Rico are geographically isolated from the continental United States. To address potential challenges to candidate access in those areas, blood type O livers recovered in those two donation service areas will be offered for all local candidates, regardless of blood type, before being offered to any candidates outside those areas.
Also, no transplant program exists in the state of Alaska, and all U.S. transplant programs are beyond a 500 nautical mile distance from donor hospitals in Alaska. For the purposes of this policy, any livers recovered from an Alaskan hospital will be considered as originating from the Seattle Tacoma Airport in Washington State.
A look at how the policy was developed
A message from Sue Dunn, President, Board of Directors
“The Board carefully weighed a number of options, with the ultimate goals of best honoring the gift of organ donation and helping those in greatest need. We all depend on the gift of organ donation and the contributions of one another to save and enhance the lives of transplant candidates. I know that as a community we will continue to work together to address the new system so that we make the best use of the gifts entrusted to us and provide the greatest benefit to those who need our services.”
Read the full letter here
From Sue Dunn, President, Board of Directors, December 2018
By now you may have heard about the decisions and actions our Board of Directors took at its December meeting relating to liver distribution. I’d like to provide you a bit more context about the vote, and offer information about how the Board made this decision.
The Board weighed at length a number of options. We heard the recommendations of the Liver and Intestinal Organ Transplantation Committee and the primary themes of public comment. We considered a number of alternatives and amendments brought by our Board members representing their constituencies.
We heard and shared strongly held views while maintaining a civil tone and discourse. (Listen to a recording of the liver proposal discussion here.) Crucially, our patient and donor family members reminded us that these discussions do not just involve impersonal “supply” or “demand,” but that the people we serve both enable and are affected by our actions.
The Board voted to support an acuity circles approach, one of the two approaches considered by the Liver Committee, modeled by the SRTR and distributed for public comment this fall. (More detail about how the sequence operates can be found here.)
Some key arguments in support of its ultimate adoption included the fact that it retains more local priority for candidates at similar levels of medical urgency. It is also potentially more responsive to geographic differences in area or population, as some areas of the country may not have liver programs within 150 or 250 miles of the donor location. Issues of concern include the potential effect on flight travel of recovery teams and the associated increase in costs, as well as the potential for lengthier time to organ recovery in some instances.
It is fair to say that any fundamental change creates new challenges we must face. The Board discussion provided us with a good sense of what the donation and transplant community must monitor closely going forward and address on an ongoing basis.
We all depend on the gift of organ donation and the contributions of one another to save and enhance the lives of transplant candidates. I know that as a community we will continue to work together to address the new system so that we make the best use of the gifts entrusted to us and provide the greatest benefit to those who need our services.
As always, thank you for your interest and participation in our national system. We all benefit from full, civil and informed discussion of the challenges and opportunities our community needs to address.