Waitlist mortality in liver transplantation: Understanding metrics, regulatory implications, and clinical management strategies

Waitlist mortality is a key quality metric in liver transplantation, reflecting the interplay of disease severity, organ availability, and clinical management at both system and center levels. A clear understanding of how waitlist mortality is defined, measured, and interpreted is essential. In this perspective, we review the current definitions of waitlist mortality and highlight important trends and predictors influencing waitlist mortality among liver transplant candidates in the United States. We discuss the implications of using waitlist mortality in center performance monitoring and review potential system- and center-level strategies to mitigate waitlist mortality, including allocation policy refinements, candidate selection practices, donor utilization, and clinical management while awaiting transplant. Finally, we explore future directions, including improved risk prediction, integration of waitlist mortality into continuous distribution, and the importance of equity-focused policy.