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The time to address the gorillas in the room is overdue

There are 2 gorillas in the room: (1) liver allocation in the United States is not equal by any significant metric (wait time, Model for End-Stage Liver Disease (MELD) score at transplantation, or regional review board behavior), and (2) liver allograft utilization, as demonstrated by the increasing gap between consented deceased liver donors and transplanted deceased donor allografts or the decreasing donor risk index at the time of orthotopic liver transplantation (OLT), is declining. As a community, our efforts to address the first gorilla, including the recent national implementation of the share 35 policy, have been modest, whereas organized efforts to address the second gorilla have been nonexistent. The cost of these 2 gorillas is enormous in economic, personal, and societal terms. This includes wait-list mortality, which, as a percentage of annual wait-list additions, has not significantly changed, and frustration over our inability to serve patients who are desperately ill. In this issue of Liver Transplantation, Kinkhabwala et al. analyze Organ Procurement and Transplantation Network (OPTN) data on expedited placement (EP) liver allograft codes by correlating the region of EP allograft origination, the region of EP allograft transplantation, the recipient MELD score at OLT, and early EP allograft function. The authors keenly integrate these data with their own wait-list mortality data during the study period to infer that inequity in US allocation practice has denied their patients an opportunity for OLT and call for additional regulatory oversight. While this study is successful in evoking a visceral response similar to previous studies on nationally placed allografts, it does not provide the level of inquiry needed to form definitive conclusions or direct effective policy. Most notably, EP allocation algorithms and EP allograft data are omitted. When was sequence allocation abandoned for these allografts? When was the accepting center notified of an available allograft? Who were the recovering surgeons, and what was their intent at recovery? Were they recovering for their center, another local center, a regional center, or a distant center? Was cross-clamping delayed to facilitate EP placement? Lastly, what percentage of nationally placed allografts occurs by EP versus DonorNet sequence allocation? A separate OPTN query from my group at the University of Chicago over a similar time period indicates that EP allografts accounted for less than half of all allografts allocated nationally between 2010 and 2011. These data suggests that further relevant data for the EP allograft subset are essential. The prospective incorporation of such readily available data through a standardized EP allograft worksheet to be completed by an organ procurement organization (OPO) exercising EP placement would enhance transparency while providing critical data to guide policy. Current OPTN data collection techniques do not support a structured analysis of the decision process leading to the determination of a transplantable allograft. Strengthening data collection algorithms that focus on earlier events in the donation process and incorporating new data points before recovery could improve our understanding of the decision process and increase utilization. The aforementioned EP worksheet would be invaluable in this context. The authors acknowledge that EP allografts represent a very small percentage of the deceased donor pool, which has diminished since the implementation of DonorNet. While advocating for greater oversight of