Allocation of expedited placement livers for transplantation: Efficiency at the price of equity?

Abstract

In March 2021, the United Network for Organ Sharing enacted a national policy in order to standardize the expedited placement of livers while prioritizing graft use. It remains unknown how the policy has impacted placement of these organs. We retrospectively analyzed United Network for Organ Sharing match run data, identifying livers offered from 21 March 2021 to 30 September 2023 with a bypass code indicating expedited placement. Bypass and standard allocation offers were examined with regards to organ quality, recipient outcomes, and placement patterns. A bypass code was used on 3,483 livers, of which 2,216 (69.4%) were ultimately transplanted. Expedited placement livers shared similar donor characteristics to standard allocation livers, but recipient demographics were distinct. Compared with matched standard allocation grafts, expedited placement livers demonstrated similar 1-year patient and graft survival rates. Notably, expedited placement livers were allocated to recipients significantly lower on the waitlist than recipients of matched standard allocation grafts (median rank 162.5 vs 16; P < .001). Seven organ procurement organizations (12.3%) contributed to nearly one-third of expedited placement grafts (701 livers), bypassing a median of 72 candidates per expedited placement attempt. Only 18 centers (15.6%) made up nearly 50% of expedited placement acceptances (1,109 livers). The new expedited placement policy resulted in efficient placement of select livers, achieving excellent 1-year outcomes. However, only a minority of centers benefit from use of these orphan livers. In the era of increased use of perfusion technologies obviating the relevance of cold ischemia time, out-of-sequence placement should not eclipse equitable distribution of a scarce and shared resource.