Patient selection and listing policies for liver transplantation

Liver transplantation expanded rapidly during the first three decades of its application but has undergone slower growth over the past few years because of a limited supply of donor organs. The growing discrepancy between available donor organs and patients listed for transplantation has fuelled recent debate regarding patient selection criteria and listing policies for liver transplantation. Allocation and distribution regulations of the United Network for Organ Sharing have also recently undergone changes to balance the principles of utility (i.e. the overall benefits of liver transplantation to society) and justice (i.e. the needs of the individual patient). The ideal geographical area over which organs can be distributed to balance utility and justice remains uncertain, although there are pressures to widen sharing of donor organs. The sickest patient who has been waiting the longest still receive the next available donor organ, but listing policies for the sickest patients, those with fulminant hepatic failure or acute decompensation of chronic liver disease, were recently revised. A uniform minimal listing criteria that proposes listing patients when their estimated survival with liver disease is less than that expected after liver transplantation was recently proposed and has generally been accepted. Finally, cost-outcome analyses and the reality of managed care with the transfer of financial risk from insurers to providers is beginning to have an influence on patient selection criteria.