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Allocation of Donor Livers for Transplantation: A Contemporary Struggle

Overview A crucial and unique responsibility in the management of the US transplant system involves apportioning scarce and lifesaving resources. No other area of medicine has such an acute and conspicuous need than the wait for a lifesaving organ by a patient with end-stage disease. Recognizing this challenge, the US Congress passed the National Organ Transplant Act (NOTA) in 1984, which established the Organ Procurement and Transplantation Network (OPTN) and tasked it to create a framework to ensure the optimal and fair management of transplant services. The OPTN divided the United States into 58 local areas within 11 larger regions. As the transplant field matured, the US Department of Health and Human Services published the Final Rule that interprets the OPTN statute and clarifies its intent. Together, NOTA and the Final Rule specify the OPTN’s responsibilities: establishing patient-specific priority for the equitable allocation of organs on the basis of medical judgment; increasing the organ supply; and increasing transplants for children, members of racial or ethnic minorities, and individuals with limited access to transportation.1 Efforts to improve the equity and fairness in organ allocation led to the development of an objective liver disease scoring system, Model for End-Stage Liver Disease (MELD),whichplacessickerpatients(eg,peoplewithahigh MELD score) at the top of the list to receive donor livers in their local area. The transplant community subsequently modified these policies to further prioritize the sickest patients (eg, people facing imminent death from liver disease according to their MELD score) to receive livers from donors who are located in both the local area and the broader region.