BACKGROUND: The decision to accept or decline a liver allograft for a patient on the transplant waiting list is complex. We hypothesized that surgeons are not accurate at predicting donor-specific risk. METHODS: Surgeon members of the American Society of Transplant Surgeons were invited to complete a survey in which they predicted 3-year risk of graft failure for a 53 year old man with alcoholic cirrhosis and MELD 21, with a liver from each of the following donors: 1) 30 year old local donor with traumatic brain death, or 2) 64 year old regional donor with brain death from stroke. RESULTS: Complete responses were obtained from 201 surgeons whose self-reported case volume represents 97% of liver transplants in the U.S. Surgeon-predicted 3-year graft failure risk varied widely, as shown in the histograms below with overlaid normal distribution curves. In scenario 1, 90% of respondents provided lower estimates of graft failure risk than the literature-derived estimate of 21%. In scenario 2, 96% of responses were lower than the literature-derived estimate of 40%. There was a bimodal distribution regarding the role of visual inspection of the donor liver in the decision to transplant a particular organ; two-thirds of respondents replied that visual inspection played a critical role in 10%-30% of cases, while one-fifth replied that it played a critical role in 80%-100% of cases. CONCLUSION: Surgeons vary widely in their predictions of donor-specific risk of graft failure. We have demonstrated systematic bias towards inaccurately low estimates of graft failure – particularly for higher risk organs. These findings provide impetus for development of decision support tools for organ offers.

Surgeon estimate of graft failure risk; vertical dotted line shows literature estimate (Feng et al. AJT 2006).

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