The first five liver transplant recipients were all dead within 23 days. The year was 1963, the surgeon was Dr. Thomas Starzl, and the operations were actually deemed a success for their surgical complexity. Since then, liver transplant (LT) has evolved from an experimental, often fatal procedure to the standard of care for end-stage liver disease (ESLD). Compared to the 0% 30-day survival rate of LT in 1963, the most recent 1-, 5- and 10-year survival rates of LTs in the United States are 92.6%, 79.7%, and 60.7%, respectively.

Yet, the profound success and impact of LT is not widely recognized by the public and sometimes even perceived as being dangerous. This contributes to what today is a critical problem — organ availability. In this era of successful LT, 13,338 patients wait each year for a liver, but only 8,250 transplants are performed annually. Every day, 18 Americans with ESLD die per day in the United States. As such, the loss to society incurred by failing to meet the demand of transplantable livers has never been higher, nor the need to increase organ availability more critical.

What is the opportunity cost of the current liver shortage?

In economic terms, LT can be described as a highly effective operation in great demand with a paucity in the supply of organs. As such, what is the societal opportunity cost — the value of the next best alternative – of the people who are unable to undergo transplant? And how much has the opportunity cost of LT increased as the field has advanced?

In 2018, 1201 people died on the LT waitlist, and 1343 were removed because they became too sick for an operation while awaiting an organ. A matched analysis estimated that patients with ESLD who received a LT lost seven life-years on average compared with an age and sex-matched individual in the general population. Thus in 2018, the life-years gained from a single liver transplant was 24.48 years, and one year of the organ shortage resulted in a staggering 62,227 life-years lost.

Let’s put the 62,227 life years lost in 2018 into perspective. In 1995, 840 people died on the LT waitlist, and 167 were removed because they were too sick for an operation, resulting in 24,651 life-years lost.

In the past 23 years, the United States has more than doubled the number of LTs performed per year, and still the life-years lost from the people we cannot transplant has increased by 152%. This data indicates that while the nation’s transplant capabilities are expanding, they are unable to meet the demand for organs, and the opportunity cost of the current liver shortage continues to rise.

A second, less-often publicized cost of LT is that of keeping sick patients alive on the LT waitlist. Overall, livers are allocated to the sickest patients first, which is, in part, determined by a model for end-stage liver disease (MELD) score. Unlike the kidney transplant waitlist, there are no temporizing measures such as dialysis for patients on the LT waitlist. As liver patients become increasingly ill and their MELD scores rise, they get closer to obtaining a liver but often require hospitalization for clinical stabilization. For those who did not receive an organ, the average cost of treating a patient who died on the liver transplant waitlist was approximately $74,000 per year (187.2 million total) and was mostly spent on treating complications of ESLD, including variceal bleeding, ascites, hepatic encephalopathy, and portal hypertension.

What can be done?

The liver organ shortage is a central focus of research in the field. Methods to expand the pool of transplantable livers include using more marginal organs, machine perfusion, expanding living donor programs, and even xenotransplantation in the future.

For the 13,338 people currently waiting for a liver, there are also public health interventions that, if enacted, could immediately impact on the supply of transplantable livers. Perhaps the most impactful policy intervention would be expanding the number of registered organ donors in the United States.

According to Donate Life America, 95% of Americans agree with organ donation, but only 58% are registered donors. A bold solution to this problem would be converting the United States from an opt-in system to an opt-out system, such that all citizens would be donors by default unless they actively chose otherwise. The success of a national opt-out system was demonstrated in Spain, where the presumed consent construct of solid organ donation was introduced in 1979. Today, Spain benefits from a population where only 13% of people refuse to donate organs (the highest organ donor rate in the world), versus 37% in the United Kingdom and 42% in the United States.

However, there are several impediments to the implementation of an opt-out system in the United States. In a country that is suspicious of government involvement, laws that set organ donation after death as a default can be viewed as intrusive. Also, some leaders in the transplant community fear that an opt-out system will decrease the number of registered donors because of a high opt-out rate. The debate here is one of default perspective. Once the act of organ donation is no longer viewed as extraordinary by society, the opt-out rates remain low, as seen in Spain.

A call to action

Currently, the stakes of LT have never been higher. As outcomes of LT continue to improve, the life-year and monetary costs of the national liver organ shortage increase. The success of LT makes the preventable losses larger. Over 2,500 Americans on the liver transplant waitlist die of a treatable medical condition each year, amounting to 62,227 life-years lost per year and over $187.2 million spent annually on medical care alone.

These are patients who have health insurance, are well incorporated into the United States medical system, and are seen by multiple specialists, whose pre-LT care involves time and resources that ultimately go to waste if they are unable to undergo LT.

Taken together, the data should be a call to action for health policymakers and UNOS to challenge the nation’s status quo with respect to organ donation. Liver transplantation is a field that has made tremendous strides in its capacity to cure chronic illness. It is now time for organ donation policies to follow suit.

Omar Haque is a surgery resident. Khalid Khwaja is a transplant surgeon. Bapu Jena is an internal medicine physician.

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