Declined Organs for Liver Transplantation: A Right Decision or a Missed Opportunity for Patients with Hepatocellular Carcinoma?

SIMPLE SUMMARY: Every declined organ is a missed opportunity that increases mortality on the waiting lists. There are many reasons why an organ may be declined for transplantation. To better understand this complex situation, we analyzed the factors involved in organ allocation in our transplant center. This study has shown that 50% of potentially suitable organs are declined. This indicates that decision-making is not standardized during allocation, and that whether to accept or decline an organ is at the discretion of the transplant teams, who evaluate the organ risk based on the information available. Our results show that, while an organ might be unsuitable for one recipient, it might be suitable for another. We also show that patient care can be improved and emphasize the need for optimized allocation protocols to avoid unnecessary declination of organs. This is particularly relevant to major extended donor criteria grafts, which are becoming the new “standard” and need specific allocation policies. ABSTRACT: Background: Liver transplantation is the only promising treatment for end-stage liver disease and patients with hepatocellular carcinoma. However, too many organs are rejected for transplantation. Methods: We analyzed the factors involved in organ allocation in our transplant center and reviewed all livers that were declined for transplantation. Reasons for declining organs for transplantation were categorized as major extended donor criteria (maEDC), size mismatch and vascular problems, medical reasons and risk of disease transmission, and other reasons. The fate of the declined organs was analyzed. Results: 1086 declined organs were offered 1200 times. A total of 31% of the livers were declined because of maEDC, 35.5% because of size mismatch and vascular problems, 15.8% because of medical reasons and risk of disease transmission, and 20.7% because of other reasons. A total of 40% of the declined organs were allocated and transplanted. A total of 50% of the organs were completely discarded, and significantly more of these grafts had maEDC than grafts that were eventually allocated (37.5% vs. 17.7%, p < 0.001). Conclusion: Most organs were declined because of poor organ quality. Donor-recipient matching at time of allocation and organ preservation must be improved by allocating maEDC grafts using individualized algorithms that avoid high-risk donor-recipient combinations and unnecessary organ declination.