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Out-of-Sequence Allocation in Liver Transplantation: A Poorly Used Tool to Improve Organ Utilization
Chase J Wehrle1, Abby Gross1, Sangeeta Satish1
1Transplant Research Center, Cleveland Clinic Foundation, Cleveland, OH.
Annals of Surgery
|April 21, 2025
Summary
Out-of-sequence (OOS) liver allocation can improve the utilization of high-risk deceased donor grafts. However, current practices do not consistently align OOS use with graft risk, indicating potential for improved application.
Area of Science:
- Transplant surgery
- Organ allocation
- Public health
Background:
- Deceased donor liver allocation traditionally uses a ranked match-run system.
- Organ procurement organizations (OPOs) can deviate using out-of-sequence (OOS) matches.
Purpose of the Study:
- To evaluate the impact of OOS matches on organ utilization.
- To identify factors influencing the decision to use OOS matches.
Main Methods:
- Analysis of eligible deceased donors from the Scientific Registry of Transplant Recipients (SRTR) data (2013-2023).
- Utilized hierarchical mixed-effects models to assess OOS practices versus organ utilization.
- Controlled for liver graft risk using the Discard Risk Index (DSRI), blood type, and year.
Main Results:
- Out-of-sequence (OOS) offers increased annually but did not correlate with overall increased organ utilization.
- Increasing graft risk was associated with reduced utilization for deceased donor (DBD) and donation after cardiac death (DCD) grafts.
- OOS allocation improved utilization for DCD grafts across all risk levels and for high-risk DBD grafts.
Conclusions:
- Out-of-sequence (OOS) allocation demonstrates potential to improve utilization of high-risk grafts.
- Current OOS practices are not optimally aligned with graft risk, suggesting a need for refinement in application.
