Executive summary

Currently there is significant variation in a liver transplant candidate’s chances of receiving a lifesaving organ offer depending on where they live and the location of the transplant hospital where they are listed. In March 2000, the US Department of Health and Human Services (HHS) implemented the Final Rule, which instructs that OPTN/UNOS allocation policies must, among other factors, be based on sound medical judgment, seek to achieve the best use of donated organs, and shall not be based on the candidate's place of residence or place of listing except to the extent needed to satisfy other regulatory requirements.¹ The OPTN/UNOS recognizes that there are not enough organs for patients in need of lifesaving transplant and is invested in increasing the number of transplants each year by increasing donation, reducing organ discards, and improving OPO performance.²

However, these efforts will not change the fact that the current regional boundaries often physically separate areas with a greater number of candidates from areas with comparably more eligible donors. The result is that in some areas of the United States, candidates must reach a much higher MELD or PELD score in order to get a transplant.³ Among the current OPTN/UNOS regions in 2015, the difference in median MELD at transplant is as great as 12 points (35 vs 23), the equivalent of a 60 percentage point difference in the estimated risk of 3-month mortality without a liver transplant.⁴

This proposal seeks to modify these boundaries to better match organ supply with demand, ensuring more equitable access for those in need of liver transplant regardless of their place of residence or listing. To prepare for this necessary next step, the OPTN/UNOS Liver and Intestinal Organ Transplantation Committee has been engaged in an inclusive, consensus-driven process to develop this proposal. The Committee proposes eight mathematically-optimized districts with additional priority of 3 MELD or PELD points for those candidates that are both within the district and a 150-mile radius of the donor hospital upon initial district-wide sharing. The Committee proposes district-wide sharing of adult deceased donor livers for all candidates with a MELD or PELD of at least 29 before introducing local (DSA) priority.

A liver policy webinar was held on August 19th. You can find a recording at UNOS Connect, UNOS' learning management system. 

Learn more about liver allocation and distribution policy.

1. 42 C.F.R. § 121.8
2. Organ Procurement and Transplantation Network. “OPTN Strategic Plan.” Richmond, VA, 2014, available at: https://optn.transplant.hrsa.gov/governance/strategic-plan/.
3. A liver candidate receives a Model for End-Stage Liver Disease (MELD) score or, if less than 12 years old, a Pediatric End Stage Liver Disease (PELD) score that is used for liver allocation. The score is intended to reflect the candidate’s disease severity, or the risk of 3-month mortality without access to liver transplant.
4. Based on OPTN data as of July 1, 2016