REGULATORY ISSUES AND QUALITY IMPROVEMENT: Edited by Aaron AhearnStriving for more just allocation of liver allografts between patients with and without hepatocellular carcinoma successes and challengesAhearn, AaronAuthor Information Department of Surgery, Keck Medical Center of USC, Los Angeles, California, USA Correspondence to Aaron Ahearn, MD, PhD, University of Southern California, Los Angeles, California, USA. E-mail: Aaron.Ahearn@med.usc.edu Current Opinion in Organ Transplantation: February 2020 - Volume 25 - Issue 1 - p 42-46 doi: 10.1097/MOT.0000000000000727 Buy Metrics Abstract Purpose of review Recently the United Network for Organ Sharing (UNOS) adopted new rules for the allocation of liver allografts for recipients with hepatocellular carcinoma (HCC) in hopes of removing regional variation in HCC practice and regional differences in patient survival. Understanding how previous changes to HCC allocation have both succeeded and failed to match the pretransplant mortality of HCC and non-HCC patients on the waitlist will help us to better evaluate these changes and predict where we may again fail. Recent findings Previous revisions of the HCC allocation rules were successful in more accurately matching the waitlist mortality of HCC and non-HCC patients. Efforts to select for less aggressive tumor biology have resulted in better disease free and patient survival. Several articles have also supported the practice of using locoregional therapies to downstage the patients to within Milan criteria. New rules seek to reduce the amount of geographic disparity in the allocation system. Summary Over time UNOS has steady improved the liver allocation polices to attempt to match pretransplant mortality for patients with HCC and without HCC. The latest changes to the organ allocation rules succeed in implementing some of these best practices. However, one can also predict several ongoing challenges to fair allocation that may not have been addressed by recent changes. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.