Allocation of Liver Grafts Worldwide Is there a best System

Abstract Background 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 (LT) are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). Large differences however exist between centers and countries for ethical and legislative reasons. Aim To report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages. Methods Countries around the world performing ≥ 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics. Results/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 as well as morbidity, and perhaps costs. Lay Summary An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. 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 as well as morbidity, and perhaps costs.