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Evolution of out-of-sequence liver allocation, 2019-2024.

Jacqueline B Henson1, Xuyang Xia2, Ryan McDevitt3

  • 1Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.

American Journal of Transplantation : Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons
|January 29, 2026
PubMed
Summary
This summary is machine-generated.

Allocation out-of-sequence (AOOS) in liver transplants is increasing, with concentrated use in specific regions and centers. While not linked to overall donor yield, AOOS acceptance by transplant centers correlates with better organ offer acceptance.

Keywords:
Organ Procurement Organizationsliver transplantationorgan allocationtissue and organ procurement

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Area of Science:

  • Transplantation Medicine
  • Organ Allocation Systems
  • Hepatology

Background:

  • Allocation out-of-sequence (AOOS) allows deviations from standard deceased donor organ allocation to expedite placement.
  • Contemporary practices and impact of AOOS in liver transplantation remain incompletely understood.

Purpose of the Study:

  • To characterize current liver AOOS practices, including prevalence, timing, and geographic distribution.
  • To examine the association between AOOS and organ utilization and offer acceptance rates.

Main Methods:

  • Analysis of liver match runs from 2019-2024 using the OPTN Potential Transplant Recipient dataset.
  • Incorporation of Scientific Registry of Transplant Recipients data for program- and OPO-specific utilization analysis.
  • Assessment of AOOS prevalence, timing, geographic variability, and correlation with adjusted utilization metrics.

Main Results:

  • AOOS allocation increased significantly from 5% in 2019 to 18% in 2024.
  • AOOS use was concentrated in specific Organ Procurement Organizations (OPOs) and transplant centers, often geographically linked.
  • AOOS offers were initiated earlier in the allocation process over time.
  • OPO-level AOOS use did not correlate with donor yield, but center-level AOOS acceptance was linked to higher adjusted offer acceptance.

Conclusions:

  • Liver AOOS practices show increasing use and geographic concentration.
  • AOOS acceptance by transplant centers may improve organ offer acceptance.
  • Further standardization of AOOS practices in liver transplantation is warranted.