Demand, Waitlisting and Transplantation Around the World: The Axiomatic View of Scarcity in Liver Transplantation

Liver transplantation (LT) significantly improves survival and quality of life for patients with end-stage liver disease. Whilst it is believed that need for LT vastly exceeds organ supply, quantifying the demand accurately is challenging. The performance metrics of the transplant system, such as waitlist mortality, may be misleading as they capture only patients who are referred, evaluated and listed for LT. Although means of increasing organ availability are available, they have financial costs and may be technically and ethically challenging (such as live donation and normothermic regional perfusion). The imperative to embrace these techniques can be obscured if the waitlist is assumed to be representative of the actual demand for transplantation.

An international comparative analysis of transplantation, donation and waitlist outcomes versus measures of demand for LT was performed using publicly available data.

The comparative analysis revealed no correlation between disease prevalence and waitlist metrics across jurisdictions internationally, suggesting that waitlisting practices are largely independent of actual LT demand and are constrained by other factors.

Adult LT systems globally are supply driven and uncorrelated to demand, implying that all jurisdictions are unable to meet the demand of their community and are limited by the supply of viable organs. The study underscores the inadequacy of waitlist data in representing true demand and highlights the need for improved data to inform LT policy and practice to improve access to this life-enhancing and life-saving treatment.