Criteria for Liver Transplant Listing: An Exhaustive Guide

Introduction

Liver transplantation treats end-stage liver disease and acute liver failure. Because donor organs are scarce, U.S. policy uses standardized medical urgency scores, exception pathways, and distance-based sharing to balance fairness, urgency, and utility.

Allocation Framework (Acuity Circles → Continuous Distribution)

Since 2020, Acuity Circles replaced regional/DSA boundaries with distance-based sharing from the donor hospital, reducing geographic disparities. The community is transitioning toward a unified continuous distribution framework that will weight multiple factors (e.g., medical urgency, post-transplant survival, proximity) on a common scale.

Candidates are no longer “region-bound” as in the past; distance and urgency drive offers, with continuing policy development.

MELD 3.0: Scoring & Priority

Exceptions & Special Circumstances

Exception policy details are periodically updated; transplant programs submit to the NLRB with documentation.

Compatibility & Other Matching Factors

• ABO blood type compatibility: core safety criterion in matching.
• Size considerations: donor–recipient size matching (including split grafts/pediatric needs) affects suitability.
• Logistics: even under Acuity Circles, travel time/cold ischemia and center acceptance practices matter.

Types of Liver Transplants

• Deceased donor: brain-death or circulatory-death donors.
• Living donor: partial graft from a living donor (usually right/left lobe).
• Split liver: one deceased donor liver divided for two recipients (often adult + pediatric).
• Domino: select metabolic indications where recipient’s explanted liver is transplanted into another recipient.

Outcomes and early allograft dysfunction (EAD) are tracked with standardized definitions in modern cohorts.

Living Donor Considerations

Programs evaluate donor suitability (medical, psychosocial, anatomic) with center-specific thresholds; some centers consider older donors or controlled comorbidities when risk is acceptable. Donor safety is paramount and independent advocacy is required.

Anatomical Variations & Planning

Variant arterial, venous, or biliary anatomy (e.g., accessory hepatic arteries, replaced right hepatic artery, bile duct variants) is common and often managed with tailored operative planning based on high-quality imaging and intraoperative assessment.

Conclusion

Modern listing weighs medical urgency (MELD 3.0), standardized exceptions, and distance-based sharing—moving toward continuous distribution. Candidate counseling should address compatibility, donor options (including living donation), and anatomic/center factors that influence offers.

References

1. OPTN. Improving Liver Allocation: MELD 3.0 FAQ (implementation June–July 2023).
2. OPTN Policies. Improving Liver Allocation: MELD, PELD, Status 1A/1B (effective July 13, 2023).
3. Kim WR, et al. MELD 3.0 model (adds albumin & sex; refines MELD-Na). Hepatology. 2021.
4. OPTN/UNOS. Acuity Circles policy replacing regions/DSAs (policy notices 2020; overview updates).
5. OPTN. Continuous Distribution of Liver & Intestine (framework and implementation planning, 2023–2025).
6. OPTN. MELD 3.0 & PELD-CR Monitoring Reports (3-, 6-, 12-month; 2024–2025).
7. NLRB Guidance. Adult MELD Exceptions for Transplant Oncology (HCC) (updated 2025).
8. Olthoff KM, et al. Early allograft dysfunction definition/validation. Liver Transplantation. 2015.
9. Varotti G, et al. Anatomic variations in right liver living donors. J Am Coll Surg. 2005.
10. Volk ML, et al. Selection committee decision-making. Ann Intern Med. 2011.

These sources summarize U.S. policy and evidence as of October 2025; consult current OPTN policy pages for any subsequent updates.