TTR-amyloidosis (FAP) is caused by TTR variants expressed and secreted by the liver. Therefore, liver transplantation was introduced as therapeutic option to prevent or limit systemic disease progression in this fatal disease. In Germany domino liver transplantation (DLT) was introduced in 1996. Since then 3-8 DLTs were performed each year in Germany. Domino livers were allocated on basis of the policy of the individual transplant center. In 2011 Eurotransplant changed this policy without any scientific debate in Germany. Domino livers are now allocated according to the ET allocation rules, which utilize the MELD score since December 2006. Currently patients receive organ offers as liver transplant recipients once MELD is far beyond 30 points. 1-year mortality has reached around 30% after liver transplantation. This presentation will highlight, that the current policy of allocating FAP livers violates the German transplant law. Apart from legal issues, there are also medical, ethical, and surgical reasons to practise allocation as it is performed in living donation in Germany. There seems to be a need for individual consent of the domino recipient in i) reflexion of TTR genotype/phenotype and potentially investigational drug treatment, ii) very careful selection of the domino recipient (age, disease, comorbidity), iii) planning of surgery including need of vessels from the donor for the FAP patient, and iv) very experienced medical follow-up of the DLT recipient. In conclusion, this topic symbolizes the need for clear legal frames for organ allocation in Germany.

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