Recipient and Donor Selection and Transplant Logistics: The US Perspective

  • Ingo Klein
  • Johanna Wagner
  • Claus U. Niemann


Organ allocation for donor livers in the US follows an algorithm of medical urgency determined by 3-month mortality risk based on objective laboratory values that are included in the MELD score. However, in a significant proportion of waitlist patients (patients with HCC and non-cirrhotic patients) the 3-month mortality risk may not be reflected by standard laboratory tests accurately. Therefore, so called exceptional MELD points based on statistical mortality risk can be granted upon standard or non-standard request. Additionally, based on urgency, the prioritization of organ recipients is embedded in a framework of local and regional distribution, resulting in significant geographical discrepancies in the US with regard to waiting time and severity of disease at the time of transplant. Changes of the current allocation and distribution policies are evaluated but have to balance increased cold ischemia times and cost efficiency with equity. While the number of ‘standard...


MELD score Child score Share 35 Waiting time Liver allocation Donor management 


  1. 1.
    Based on OPTN data as of April 8, 2017. 2004 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994–2003. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; Richmond, VA: United Network for Organ Sharing; Ann Arbor, MI: University Renal Research and Education Association.Google Scholar
  2. 2.
    Busuttil RW, Tanaka K. The utility of marginal donors in liver transplantation. Liver Transpl. 2003;9(7):651–63.CrossRefGoogle Scholar
  3. 3.
    Alonso O, et al. Advanced donor age increases the risk of severe recurrent hepatitis C after liver transplantation. Transpl Int. 2005;18(8):902–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Freeman RB Jr, Edwards EB. Liver transplant waiting time does not correlate with waiting list mortality: implications for liver allocation policy. Liver Transpl. 2000;6(5):543–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Kamath PS, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70.CrossRefGoogle Scholar
  6. 6.
    Wiesner RH, et al. MELD and PELD: application of survival models to liver allocation. Liver Transpl. 2001;7(7):567–80.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Network-HRSA, O.P.a.T. Final rule with comment period. Federal Register. 1989;63:16296–338.Google Scholar
  8. 8.
    Transplantation., C. o.O.P.a. Assessing current policies and the potential impact of the DHHS final rule. Washington, DC: National Academy Press; 1999.Google Scholar
  9. 9.
    McDiarmid SV, Anand R, Lindblad AS. Development of a pediatric end-stage liver disease score to predict poor outcome in children awaiting liver transplantation. Transplantation. 2002;74(2):173–81.CrossRefGoogle Scholar
  10. 10.
    Wiesner R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91–6.CrossRefGoogle Scholar
  11. 11.
    Sharma P, et al. Liver transplantation for hepatocellular carcinoma: the MELD impact. Liver Transpl. 2004;10(1):36–41.CrossRefGoogle Scholar
  12. 12.
    Biggins SW, Kim WR, Terrault NA, Saab S, Balan V, Schiano T, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 2006;130:1652–60CrossRefGoogle Scholar
  13. 13.
    Nekrasov V, Matsuoka L, Rauf M, Kaur N, Cao S, Groshen S, Alexopoulos SP. National Outcomes of Liver Transplantation for Model for End-Stage Liver Disease Score ≥40: The Impact of Share 35. Am J Transplant. 2016 Oct;16(10):2912–24. doi: 10.1111/ajt.13823. Epub 2016 May 13.CrossRefPubMedGoogle Scholar
  14. 14.
    Gentry SE, Chow EK, Massie A, Luo X, Shteyn E, Pyke J, Zaun D, Snyder JJ, Israni AK, Kasiske B, Segev DL. Liver sharing and organ procurement organization performance under redistricted allocation. Liver Transpl. 2015;21(8):1031–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Schaubel DE, et al. Survival benefit-based deceased-donor liver allocation. Am J Transplant. 2009;9(4 Pt 2):970–81.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Wiesner RH. Patient selection in an era of donor liver shortage: current US policy. Nat Clin Pract Gastroenterol Hepatol. 2005;2(1):24–30.CrossRefGoogle Scholar
  17. 17.
    Lopez-Navidad A, et al. Successful transplantation of organs retrieved from donors with bacterial meningitis. Transplantation. 1997;64(2):365–8.CrossRefGoogle Scholar
  18. 18.
    Fischer SA. Emerging viruses in transplantation: there is more to infection after transplant than CMV and EBV. Transplantation. 2008;86(10):1327–39.CrossRefGoogle Scholar
  19. 19.
    Kauffman HM, McBride MA, Delmonico FL. First report of the united network for organ sharing transplant tumor registry: donors with a history of cancer. Transplantation. 2000;70(12):1747–51.CrossRefGoogle Scholar
  20. 20.
    Feng S, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant. 2006;6(4):783–90.CrossRefGoogle Scholar
  21. 21.
    Berenguer M, et al. Contribution of donor age to the recent decrease in patient survival among HCV-infected liver transplant recipients. Hepatology. 2002;36(1):202–10.CrossRefGoogle Scholar
  22. 22.
    Burdelski MM, Rogiers X. What lessons have we learned in pediatric liver transplantation? J Hepatol. 2005;42(1):28–33.CrossRefGoogle Scholar
  23. 23.
    Tuttle-Newhall JE, et al. Organ donation and utilization in the United States: 1998–2007. Am J Transplant. 2009;9(4 Pt 2):879–93.CrossRefPubMedGoogle Scholar
  24. 24.
    Chan EY, et al. Ischemic cholangiopathy following liver transplantation from donation after cardiac death donors. Liver Transpl. 2008;14(5):604–10.CrossRefPubMedGoogle Scholar
  25. 25.
    Abt PL, et al. Survival following liver transplantation from non-heart-beating donors. Ann Surg. 2004;239(1):87–92.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    McCormack L, Dutkowski P, El-Badry AM, Clavien PA. Liver transplantation using fatty livers: always feasible? J Hepatol. 2011;54(5):1055–62. Scholar
  27. 27.
    Novitzky D, et al. Change from aerobic to anaerobic metabolism after brain death, and reversal following triiodothyronine therapy. Transplantation. 1988;45(1):32–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Cooper DK, Novitzky D, Wicomb WN. The pathophysiological effects of brain death on potential donor organs, with particular reference to the heart. Ann R Coll Surg Engl. 1989;71(4):261–6.PubMedPubMedCentralGoogle Scholar
  29. 29.
    DuBose J, Salim A. Aggressive organ donor management protocol. J Intensive Care Med. 2008;23(6):367–75.CrossRefPubMedGoogle Scholar
  30. 30.
    Roth BJ, et al. Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service. Clin Transpl. 2003;17(Suppl 9):52–7.CrossRefGoogle Scholar
  31. 31.
    Franklin GA, et al. Optimization of donor management goals yields increased organ use. Am Surg. 2010;76(6):587–94.PubMedGoogle Scholar
  32. 32.
    Niemann CU, Feiner J, Swain S, et al. Therapeutic hypothermia in deceased organ donors and kidneygraft function. N Engl J Med 2015;373:405-414.CrossRefPubMedGoogle Scholar
  33. 33.
    Ghobrial RM, et al. Donor morbidity after living donation for liver transplantation. Gastroenterology. 2008;135(2):468–76.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Roberts JP, et al. Influence of graft type on outcomes after pediatric liver transplantation. Am J Transplant. 2004;4(3):373–7.CrossRefPubMedPubMedCentralGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of General- and Visceral-, Vascular and Pediatric SurgeryUniversity of Wuerzburg, Medical CenterWuerzburgGermany
  2. 2.Anesthesia and Perioperative Care, Department of SurgeryUniversity of California San FranciscoSan FranciscoUSA

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