Reply: Estimating the cost of liver transplantation

We thank Drs Lankarani and Lankarani for their thoughtful correspondence regarding our recent review on the rising cost of liver transplantation (LT) in the United States. Their comments highlight meaningful dimensions of transplant economics, including system-level perspectives, equity considerations, and international experiences. We welcome the opportunity to clarify the scope and context of our analysis. Our manuscript was written as a review and opinion piece by a panel of LT experts from multiple US transplant centers, with the goal of describing the rapidly evolving cost pressures faced by US programs.1 These include organ acquisition costs, transportation and logistical demands under broader distribution, adoption of machine perfusion, workforce constraints, and stagnant reimbursement. Because these cost drivers arise within a decentralized, multi-payer US healthcare system, our review focused deliberately on US-specific program-level forces. We agree that distinguishing “cost,” “charge,” and “reimbursement” is essential. As noted in our introduction, we focused on costs and referenced charges or net revenue only when these were the financial metrics reported in the literature. The authors also raise the importance of comparing LT costs with the broader societal burden of end-stage liver disease (ESLD). Although our review centered on operational and programmatic pressures, we agree that LT is cost-saving over a patient’s lifetime. Regarding machine perfusion technologies and Organ Procurement Organization (OPO) acquisition fees, our review highlighted concerns around pricing, transparency, market consolidation, and regional variability. We agree that continued regulatory oversight and clearer reporting will be essential to ensure equitable access and prevent inappropriate cost escalation. We also appreciate the emphasis on ethical and equity considerations, including patient financial toxicity. While this was not the primary focus of our review, members of our author group have published extensively on this topic, demonstrating substantial financial strain among LT recipients and outlining barriers to achieving financial neutrality for living donors.2,3 These efforts reflect our shared commitment to addressing patient-centered economic challenges alongside program-level cost issues. Lastly, the correspondence compares the US LT economics with Iran’s government-funded transplant system. While international models can offer valuable insights, several foundational differences limit their relevance to US cost analysis. Iran’s LT system is fully government-funded, reimbursed through fixed national tariffs, and operates within a centralized structure fundamentally distinct from the US multi-payer environment. Transplant volume is also substantially smaller, with 4500 LTs performed over a > 20-year period in Iran compared with >10,000 LTs performed per year in the United States.4 Lastly, Iran permits financial compensation for living donors, which is explicitly prohibited under US federal law.5 These structural, regulatory, and ethical differences significantly alter donor incentives, cost structures, and economic modeling, and therefore cannot serve as a meaningful comparator for evaluating US-specific cost drivers or policy solutions. We thank the authors for engaging thoughtfully with our work. Their commentary underscores the need for continued dialogue on the economic, ethical, and global dimensions of transplantation, and we hope our review contributes meaningfully to these ongoing discussions.