Objectives: 1) Evaluate liver allograft availability, utilization, and failure probability utilizing the liver donor risk index(LDRI) 2) Correlate allograft utilization with waitlist mortality and incidence of early allograft failure.

Methods: A Scientific Registry of Transplant Recipients search of US adult, initial liver-only transplant, from 01/01/03 through 12/31/13 identified 44686 transplants from 75, 516 consented donors. Allograft origin (local [LCL], regional [RGN], or national [NTL]), LDRI, mechanism of donation (DBD or DCD), waitlist mortality, and emergent relisting for early allograft failure were evaluated.

Results: Consented DBD and DCD donors increased 15% and 391%, respectively; however, transplanted allografts increased by only 9% for DBD and 196% for DCD (p<0.01). The probability of consented DBD or DCD donors yielding a transplant each declined to a low of 82% and 27%, respectively. Overall DRI fell for both DBD (2%) and DCD (11%) despite changing demographics that inflate DRI (p<0.05). LCL utilization increased while NTL significantly declined. LCL and RGN median LDRI were not significantly different over the study period while NTL median LDRI significantly decreased (p<0.05). Waitlist mortality has not improved while the incidence of emergent retransplantation for early allograft failure is a decade low 0.8%.

Conclusion: Increases in consent have not yielded equivalent increases in transplant activity or decreased waitlist mortality. Lower utilization of high-risk allografts and a very low incidence of early allograft failure imply current donor acceptance practices are inadequate to extract the full potential of the existing donor pool and reduce waitlist deaths.

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