Plateauing Deceased Donor Liver Utilisation Presents Emerging Challenges for Liver Transplantation in Australia

INTRODUCTION: For many patients, liver transplantation (LT) is not feasible due to a shortfall of suitable organs. In Australia, almost all grafts come from deceased donors, a pool not easily expanded, and many potentially useable grafts are declined for viability concerns. Despite this, referral utilisation is incompletely understood. The objective of this paper was to characterise deceased donor liver utilisation and referral patterns at a major Australian LT unit. METHODS: All deceased donor referrals made to the Australian National Liver Transplantation Unit (ANLTU) from 2014 to 2024 were included. The primary endpoint was the utilisation rate of referrals made to the ANLTU. Secondary endpoints included the effect of referring hospital location on utilisation, reason for decline and donor characteristics. RESULTS: A total of 1649 referrals were included. During the study period, out-of-network referral volume increased significantly, from 23 to 77 annually (p = 0.044). Overall, utilisation fell from 61.3% to 43.2% (p = 0.045), due to falling utilisation of out-of-network referrals. In-network donation after neurological determination of death (DNDD) and circulatory determination of death (DCDD) referral utilisation was stable at 65.3% (p = 0.979) and 30.0% (p = 0.621), respectively. In-network referrals were increasingly declined due to an absence of a suitable potential recipient (p = 0.003) and out-of-network due to the graft being unsuitable for the urgently listed patient (p = 0.038). CONCLUSION: Utilisation of in-network referrals has remained unchanged since 2014. Out-of-network referral volume is increasing, with reduced utilisation of grafts amongst this cohort. Techniques to improve organ utilisation will be critical to expand access to LT in Australia.