Should we use liver grafts repeatedly refused by other transplant teams

Abstract Background & Aims In France, liver graft refused at least five times can be "rescued" and allocated to a centre which chooses a recipient from its own waiting-list, instead of a patient-based allocation frame. We explored whether these "rescued" grafts penalise grafts'/patients' survival or affect the survival benefit. Methods Among 7895 candidates, 5218 were transplanted between 2009 and 2014 (336 centre-allocated). We compared recipients/grafts survival between patient- and centre-allocation, considering a selection bias and the distribution of centre-allocation recipients among the transplant teams. We used a propensity score approach and a weighted Cox model using the Inverse Probability of Treatment Weighting method. We also explored the survival benefit associated with centre-allocation grafts. Results Centre-allocation patients experienced a significant 13% higher graft loss/death versus the patient-allocation group (HR:1.13[1.05-1.22]). However, this difference was no longer significant for teams performing more than 7% of centre-allocation transplantation. Moreover, receiving a centre-allocation graft, compared to remaining on the waiting-list and possibly later receiving a patient-allocation graft, did not convey a poorer survival benefit (HR:0.80[0.60-1.08]). Conclusions In centres which transplanted most of the centre-allocation grafts, using grafts repeatedly refused for top-listed candidates was not detrimental. Given the organ shortage, our findings should encourage policy makers to restrict centre-allocation grafts to targeted centres.