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Opportunity in a Crisis: We Can Do Better

Gallagher, Tom K. MD, FRCSI1

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doi: 10.1097/TP.0000000000003492
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The increase in the incidence of overdose-related deaths in the United States has resulted in an increasing number of organ donations,1 and has contributed to a decreased number of people on the waiting list for all organs.2 Opioid-associated deaths most often occur in young donors, who frequently have healthier organs than older donors, and so quite correctly, Yoeli et al3 hypothesize in this issue that, in spite of the tragedy that is the opioid crisis in the United States, there is likely an opportunity for liver transplant units to seize the initiative and increase the number of split liver transplants performed from these healthier livers, thereby increasing further the number of transplants performed while this crisis persists.

The authors have elegantly compared trends in use of drug overdose (DO) donors in adult versus pediatric liver transplants and the utilization of split liver transplantation in this donor population using the UNOS database. While adult liver transplants from DO donors increased from 2% in 2002 to 15% in 2017, pediatric liver transplants from DO donors only increased from <1% to 3% in the same time—for context, a total of 12 DO donor liver transplants in 2013 was the peak in the pediatric population. Excellent adult and pediatric outcomes from DO donors were noted throughout. There are a number of points to consider based on these data.

First, the use of DO donors has increased not only as an absolute number over the timeframe of the study but as a proportion of donors, thereby highlighting the improvements made in the diligent and specific screening methods that permit organs previously considered unacceptable to be now acceptable for transplantation, with a lower risk for recipients than the risk of turning down the donated organ altogether.3 However notwithstanding the fact that DO donors were younger and less likely to have comorbidities such as diabetes or hypertension, recipients of DO donor livers were more likely to have alcohol-related liver disease and to have waited longer on the waiting list. DO donors were more likely to be designated Public Health Service Increased Risk and despite evidence demonstrating equivalent outcomes in recipients of these donor organs, the ongoing reluctance to use these donors implies perhaps a bias in donor selection for these particular recipients. This implicit bias needs to be evaluated and addressed as its relationship with healthcare outcomes is never more obvious than in waitlist mortality figures.

Second, the proportion of donors being split among those who met eligibility criteria in the United States was disappointing. While 28% of DO donors met splitting criteria, only 84 of 1042 Hepatitis C-negative DO donors meeting criteria were split. By comparison, just 7% of the transplanted non-DO donor grafts meeting eligibility were split. Interestingly more donors were split out with criteria than within (48:36), suggesting that individual surgeon and unit preference plays a key role in the data we are seeing in this article.

Unfortunately, in the United States, there are no UNOS rules to compel a program to split a liver and share it. It is likely that there are many reasons why units do not do so voluntarily. Some argue that a large portion of the disincentive is simply logistical. A 2019 OPTN/UNOS proposal4 to address Split Liver Variance, whereby participating liver programs would be permitted to split a liver; transplant the first segment into the candidate to whom it was allocated, and the remaining segment into another candidate at the same or affiliated hospital after offering the remaining segment to the most urgent candidates within 500 miles. Some opposed any splitting mandate under the assumption that adult candidates who are listed at programs without an institutionally affiliated pediatric program may be disadvantaged. The counter argument to this being that limiting the allocation of the 2 liver segments to a single transplant center would facilitate more efficient split liver allocation and procurement. It seems that agreement in the United States is further away than ever as following the proposal, the American Society of Transplantation could not come to clear agreement within its membership to either support or oppose the proposal, and it was yet again left up to individual units to decide on policy. Beyond any rule changes, it seems the main issue that has prevented broader voluntary use of split liver transplantation in the United States is the understandable behavior of surgeons working to minimize complications in their individual patients.

Although disagreements may arise in the delivery of splitting, there is little doubt as to its benefits on a population level. It is likely that pediatric prioritization will be an important driver of split application, as has been successfully applied in the United Kingdom.5 The UK guidelines to split liver donation6 mandate that donors who meet splitting criteria must be offered for splitting if there is an appropriate pediatric recipient. Rates of splitting in programs in the United Kingdom, Brazil, and Argentina reach 10%,7 and up to 20% in Northern Italy8 as a result of mandatory pediatric offers.

It seems that surgeon and unit autonomy when it comes both to splitting policy and DO-donor recipient selection does not allow for the best population outcomes. This article will hopefully provide renewed impetus for policy reflection and change going forward.


1. Maghen A, Mone TD, Veale J. The kidney-transplant waiting list and the opioid crisis. N Engl J Med. 2019;380:2273–2274.
2. United Network for Organ Sharing. Transplants by organ type. Available at Accessed September 1, 2020.
3. Yoeli D, Choudhury RA, Nydam TL, et al. The surge in deceased liver donors due to the opioid epidemic: is it time to split the difference? Transplantation. 2021;105:2239–2244.
4. Miller E; OPTN/UNOS Liver and Intestinal Transplantation Committee. Public comment proposal: split liver variance. Available at Accessed September 1, 2020.
5. Battula NR, Platto M, Anbarasan R, et al. Intention to split policy: a successful strategy in a combined pediatric and adult liver transplant center. Ann Surg. 2017;265:1009–1015.
6. National Health Service Blood and Transplant. Policies and guidance. Available at Accessed September 1, 2020.
7. Hackl C, Schmidt KM, Süsal C, et al. Split liver transplantation: current developments. World J Gastroenterol. 2018;24:5312–5321.
8. Cillo U, Burra P, Mazzaferro V, et al. I-BELT (Italian Board of Experts in the Field of Liver Transplantation) a multistep, consensus-based approach to organ allocation in liver transplantation: toward a “blended principle model”. Am J Transplant. 2015;15:2552–2561.
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