HOPE OR EFFICACY IN DONOR LIVER ALLOCATION?

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Abstract
Both the number of recipients awaiting liver transplantation and the length of wait are increasing, giving rise to increasing concern by patients, healthcare professionals, and the public. Greater attention has been focused on the criteria for listing patients for transplantation and for allocation of organs. In the U.K., compared with the U.S., the delivery of liver transplant services is more tightly regulated, with fewer transplant centers, lower transplant rates, shorter waiting lists, and shorter waiting times. The reasons for these differences are unclear. In the U.K., patients are listed only if there is a reasonable expectation that the patient will receive a graft. The criteria for listing are based on overall utility rather than individual benefit, so the criterion for listing is that the patient will have at least a greater than 50% probability of being alive 5 years after transplantation with a quality of life that is acceptable to the patient. Although it is reasonable to offer hope to all patients, this hope should have a reasonable probability of being fulfilled. Listing patients with little likelihood of benefiting from transplantation is not helpful either for the patient, their family, or the other potential liver allograft recipients. While different systems for allocation of donor livers may be more appropriate in other settings, the process in the U.K. seems to deliver satisfactorily.