Liver distributionWhat you should know about the new liver system
Policy and system changes will be implemented in 2019. Learn more.
Important note: National liver review board implementation, originally scheduled for January 31, 2019, is postponed.
The liver distribution policy passed by the OPTN/UNOS Board of Directors in December 2018 replaces donor service areas and regions with a series of circles for distributing livers. This transformative change accomplishes multiple goals of the national transplant network and will help liver transplant candidates throughout the country.
How it will help patients
Modeling shows that under the new system:
- Fewer people will die waiting
- More children will receive a transplant
- There will be greater consistency in the geographic areas used to match liver transplant candidates with available organs
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 OPTN/UNOS Board in 2012, and the liver community has been working intensively on system improvements since 2014.
As a community, we will study all aspects of the new system when it is implemented in 2019. We will address thoroughly any unanticipated effects so that candidates have the greatest possible chance to survive and thrive with a transplant.
How the OPTN/UNOS Board reached its decision
A message from Sue Dunn, President, OPTN/UNOS 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.
Comments made during the Board’s discussion
I hope you always keep in mind all of this is only available because of the generosity of a family who wishes to help as many people as possible.
Deanna Santana, Donor mother, living donor and Board VP of Patient and Donor Affairs
We need to prioritize what’s best for the patients, and the geographic constraints need to be somewhat underprioritized.
Charlie Miller, M.D., Transplant surgeon and Director, Liver Transplant Program, The Cleveland Clinic Foundation
We’re here to serve the patients and honor the intent of the donor family.
Joseph Hillenburg, Transplant recipient father, general public representative
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 at right, 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.
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.
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).
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.
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.
- Listen to the liver proposal discussion
- Learn more about the OPTN/UNOS Liver & Intestine Committee.
- Read a letter from HRSA to UNOS reflecting the “critical comment” on use of DSAs and regions in liver policy (June 8, 2018).
- Read UNOS’ response to HRSA (June 25, 2018).
- Read a memo from OPTN/UNOS Board President Yolanda Becker, M.D. to the transplant community, which references our response to HRSA and the Executive Committee’s charge to the Liver Committee to work on an alternative liver distribution policy replacing DSA and regional boundaries (June 27, 2018).
- Read a July 31 memo from HRSA Administrator George Sigounas, M.S., Ph.D., to UNOS regarding further development of organ distribution policies.
- Read an August 13 reply from UNOS to HRSA’s memo of July 31.