Highlights
- •An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity.
- •Large differences exist between centers and countries for ethical and legislative reasons.
- •A future globally applicable strategy should combine donor and recipient factors.
- •This strategy must predict probability of death on the waiting list, post-transplant survival and morbidity, and costs.
Background & Aims
An optimal allocation system for scarce resources should simultaneously ensure maximal
utility, but also equity. The most frequent principles for allocation policies in
liver transplantation are therefore criteria that rely on pre-transplant survival
(sickest first policy), post-transplant survival (utility), or on their combination
(benefit). However, large differences exist between centers and countries for ethical
and legislative reasons. The aim of this study was to report the current worldwide
practice of liver graft allocation and discuss respective advantages and disadvantages.
Methods
Countries around the world that perform 95 or more deceased donor liver transplantations
per year were analyzed for donation and allocation policies, as well as recipient
characteristics.
Results
Most countries use the model for end-stage liver disease (MELD) score, or variations
of it, for organ allocation, while some countries opt for center-based allocation
systems based on their specific requirements, and some countries combine both a MELD
and center-based approach. Both the MELD and center-specific allocation systems have
inherent limitations. For example, most countries or allocation systems address the
limitations of the MELD system by adding extra points to recipient’s laboratory scores
based on clinical information. It is also clear from this study that cancer, as an
indication for liver transplantation, requires special attention.
Conclusion
The sickest first policy is the most reasonable basis for the allocation of liver
grafts. While MELD is currently the standard for this model, many adjustments were
implemented in most countries. A future globally applicable strategy should combine
donor and recipient factors, predicting probability of death on the waiting list,
post-transplant survival and morbidity, and perhaps costs.
Lay summary
An optimal allocation system for scarce resources should simultaneously ensure maximal
utility, but also equity. While the model for end-stage liver disease is currently
the standard for this model, many adjustments were implemented in most countries.
A future globally applicable strategy should combine donor and recipient factors predicting
probability of death on the waiting list, post-transplant survival and morbidity,
and perhaps costs.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: June 11, 2019
Accepted:
May 27,
2019
Received in revised form:
May 23,
2019
Received:
January 11,
2019
See Editorial, pages 654–656Identification
Copyright
© 2019 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
