Haugen et al1 present an important article that should change practice. Despite improved outcomes in recipients of older donor livers, rates of discard of old livers have increased significantly. Of importance, this article raises the questions of why older livers are commonly discarded and what we can do to fix this problem.
Donor logistics are a key reason for these discards. When a surgeon is in the donor operating room evaluating a liver, it is not a simple assessment to determine whether the liver is usable. Instead, the donor liver is evaluated within the context of the recipient. When the liver does not look great (like many older livers), the decision is commonly made to pass for the intended recipient, who is thought to be better off waiting for a better liver. For the liver to be used, it must be reallocated in a short amount of time. At best, it requires 4 to 6 hours to identify a new recipient and bring them in for the transplant. Other transplant teams are present in the operating room procuring other thoracic and abdominal organs. Having the entire system stop for 6 hours is rarely feasible. Also, receiving a call from a surgeon you do not know saying that “the liver does not look great, is usable, but we are passing” is not appealing. The recipient is likely just as sick as the recipient they are passing for and may also do poorly with a mediocre liver. Unfortunately, the end result is that these organs are often discarded.
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Waits SA, Englesbe MJ. Fixing the Problem of Discard of Livers From Older Donors. JAMA Surg. Published online February 13, 2019. doi:10.1001/jamasurg.2018.5587
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