Background: Based on a proposal from the Liver and Intestinal Organ Transplantation Committee, the OPTN implemented regional sharing for MELD/PELD 35+ candidates on June 18, 2013. The intent of the policy change was to reduce the waiting list mortality for the most urgent, non-Status 1 candidates. The policy was not intended to reduce the variance in the median MELD at transplant. Methods: To examine the impact of this policy, we analyzed waiting list outcomes for all candidates who first entered the allocation MELD/PELD 35+ category in the one-year period prior to implementation and the one-year period post-implementation. We also analyzed post-transplant outcomes for MELD/PELD 35+ recipients during the first 4 months of both the pre- and post-implementation eras. Results: Overall there were 328 more deceased donor liver transplants in the post-era. The variance in the median MELD at transplant increased from 14.3 to 17.6. The percentage of transplants in the MELD/PELD 35+ category increased from 18.7% in the pre-era to 26.3% in the post-era. Additionally, the percentage of regional transplants increased from 20.4% in the pre-era to 31.8% in the post-era. While the overall median distance livers traveled increased from 59 miles to 85 miles, the median CIT and DRI were unchanged. Liver discard rates dropped from 10.3% to 9.5%. The transplant rates within 90 days of first entering the MELD/PELD 35+ category were significantly higher in the post-era, while the death rates were significantly lower (see table). There were no statistically significant changes to overall waiting list mortality by region, age (pediatric vs adult), ethnicity, or within the other MELD/PELD categories. Overall 6-month patient survival rates were similar pre- and post-policy (93.6% pre, 93.4% post), as were patient survival rates among MELD/PELD 35+ recipients (90.2% pre, 90.4% post). Conclusions: The policy designed to reduce the waiting list mortality rates for the most urgent MELD/PELD candidates is working as intended, without impacting the overall post-transplant survival in the post-era. The Committee will continue to monitor the results of Share 35 and related policies.

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