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Liver

Liver policy

A federal court considering a legal challenge to the liver and intestinal organ allocation policy based on acuity circles has determined, in a ruling issued Jan. 16, 2020, not to issue an injunction on policy implementation. As a result, the OPTN implemented the policy Feb. 4, 2020.

Learn how policy is made.

Questions? Contact us at liver@unos.org.

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Overview

The OPTN is working to improve the equitable allocation of livers for transplantation for patients across the country waiting for a liver transplant.

The MELD score is used to assess liver candidates’ severity of illness. The OPTN is committed to developing policy to minimize the variance in the median MELD score at transplant across different areas of the country.

The OPTN Liver and Intestinal Organ Transplantation Committee has studied a number of possible solutions. It has widely sought public feedback on concepts to improve liver distribution and reviewed statistical modeling of the possible impact of various options.

The liver distribution policy passed by the OPTN Board of Directors in December 2018 replaces Donation 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 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.

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.

For example, 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.

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

For 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.
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

For 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 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.

For 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.

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.

Learn more

Video of how OPTN policy is made

Watch a video about how organ allocation and distribution policy is made. [Exit Disclaimer]

Background

Liver allocation and distribution policy has continued to evolve since it began in 1987. Changes over time have broadened urgent candidates’ access to liver transplantation and significantly reduced deaths among waiting list candidates.

Per the OPTN Final Rule, OPTN 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 a candidate’s place of residence or listing except to the extent required to satisfy other factors. The OPTN and transplant community must always balance these factors as organ allocation policies are created and changed.