Candidates for liver transplant with high-frequency deceased donor offers

Changes in organ allocation, technology, and regulatory policy have led to significant increases in deceased donor liver offers for transplantation. Expansion of potential donors is associated with inefficiencies, including increased liver nonutilization, resources, and complications. We evaluated the contribution of individual waitlisted candidates to the national allocation of deceased donor liver offers to understand characteristics of candidates with numerous offer turndowns. We performed an observational cohort study of the Scientific Registry of Transplant Recipients, including deceased donor liver offers in the United States between January 1, 2021, and December 31, 2024. We used standard and hierarchical multivariable logistic models to evaluate factors associated with high-frequency candidates (HFCs). There were 1,021,569 offers of 32,750 deceased donor livers to 55,124 waitlisted candidates with ≥1 offer. Waitlisted candidates had 10.4 months average waitlist follow-up and received a median of 9 (IQR=[4, 22]) offers. However, 46% of offers (n=468,699) went to 10% (HFC, n=5726), who had ≥45 offers over the period. HFC were disproportionally ages 18-39 (adjusted odds ratio [AOR]=1.58, 95% CI=1.33-1.86, relative to 70+), Black (AOR=1.31, 95% CI: 1.17-1.47, relative to White), type-O blood (AOR=1.14, 95% CI: 1.07-1.21, relative to type A), body mass index ≥35 kg/m 2 (AOR=1.17, 95% CI: 1.06-1.28, relative to body mass index=20-24 kg/m 2 ), MELD 12-17 (AOR=1.24, 95% CI: 1.15-1.34, relative to >25), metabolic dysfunction (AOR=1.32, 95% CI: 1.09-1.62, relative to cirrhosis) and history of portal vein thrombosis (AOR=1.34, 95% CI: 1.23-1.46). There was significant heterogeneity in HFC by transplant center (median=8%, IQR=[3%, 13%]), and centers with higher proportions of HFC had lower transplant rates and offer acceptance ratios ( p <0.001). HFCs who received transplants had fewer living donor transplants and transplanted with older age donors. Results indicate liver donor offers are disproportionately explained by a minority of candidates. Efforts to identify reasons for repetitive offer declines, strategic use of offer filters and transition of applicable candidates to inactive status may dramatically improve the efficiency of deceased donor liver allocation.