Dynamic Impact of Liver Allocation Policy Change on Donor Utilization

Ethan Chan; April J. Logan; Jeffrey M. Sneddon; Navdeep Singh; Guy N. Brock; William K. Washburn; Austin D. Schenk


American Journal of Transplantation. 2022;22(7):1901-1908. 

In This Article

Abstract and Introduction


Liver allocation policy was changed to reduce variance in median MELD scores at transplant (MMaT) in February 2020. "Acuity circles" replaced local allocation. Understanding the impact of policy change on donor utilization is important. Ideal (I), standard (S), and non-ideal (NI) donors were defined. NI donors include older, higher BMI donors with elevated transaminases or bilirubin, history of hepatitis B or C, and all DCD donors. Utilization of I, S, and NI donors was established before and after allocation change and compared between low MELD (LM) centers (MMaT ≤ 28 before allocation change) and high MELD (HM) centers (MMaT > 28). Following reallocation, transplant volume increased nationally (67 transplants/center/year pre, 74 post, p .0006) and increased for both HM and LM centers. LM centers significantly increased use of NI donors and HM centers significantly increased use of I and S donors. Centers further stratify based on donor utilization phenotype. A subset of centers increased transplant volume despite rising MMaT by broadening organ acceptance criteria, increasing use of all donor types including DCD donors (98% increase), increasing living donation, and transplanting more frequently for alcohol associated liver disease. Variance in donor utilization can undermine intended effects of allocation policy change.


Liver allocation policy in the United States changed on February 4, 2020.[1,2] Acuity circles replaced donation service areas (DSAs) as the geographic determinant in allocation and broad sharing replaced a predominantly local distribution system.[3] Lawsuits[4] filed by waitlisted transplant candidates argued that probability of receiving a transplant should not depend on DSA boundaries and litigation drove national policy change. In liver transplantation, differences in median MELD score at transplant (MMaT) between centers came under scrutiny. Broader sharing was predicted to at least partially reduce variance in MMaT.[5] Predictive models could not, however, address the broad array of behavioral changes likely to occur in response to new policy.

Debate preceding allocation change was heated. Proponents argued that broader sharing was necessary and consistent with the Organ Procurement and Transplantation Network (OPTN) Final Rule[6] which mandates that allocation of organs "shall not be based on the candidate's place of residence or place of listing.".[7–11] Opponents disputed OPTN methodology[12,13] and predicted that broader sharing would lengthen procurement travel, prolong ischemic times, and escalate cost.[8,14,15] Others argued that differences in MMaT between centers are rooted in varied organ procurement organization (OPO) efficiency, and feared broader sharing would not incentivize low-performing OPOs to improve.[14,16,17] Still others argued that access to care varies in urban and rural areas and that broader sharing would disadvantage healthcare-poor populations.[18] Nonetheless, with threat of external interference looming, the transplant community settled upon acuity circles as a path forward.

Significant time has passed since allocation policy change was implemented, four post-policy change interim analyses[19–22] have been completed, and continuous reassessment is appropriate. Use of every viable donor liver remains a top priority within the transplant community, and it is therefore essential to evaluate the dynamic interplay between policy change and donor utilization. Our national analyses emphasize whether a given transplant center had a MMaT above or below the national median prior to allocation change and critically examine the effect of policy change on center behavior as reflected in donor utilization.