Waitlist Outcomes of Liver Transplant Candidates Who Were Reprioritized Under Share 35

Under Share 35, deceased donor (DD) livers are offered regionally to candidates with Model for End‐Stage Liver Disease (MELD) scores ≥35 before being offered locally to candidates with MELD scores <35. Using Scientific Registry of Transplant Recipients data from June 2013 to June 2015, we identified 1768 DD livers exported to regional candidates with MELD scores ≥35 who were transplanted at a median MELD score of 39 (interquartile range [IQR] 37–40) with 30‐day posttransplant survival of 96%. In total, 1764 (99.8%) exports had an ABO‐compatible candidate in the recovering organ procurement organization (OPO), representing 1219 unique reprioritized candidates who would have had priority over the regional candidate under pre–Share 35 allocation. Reprioritized candidates had a median waitlist MELD score of 31 (IQR 27–34) when the liver was exported. Overall, 291 (24%) reprioritized candidates had a comparable MELD score (within 3 points of the regional recipient), and 209 (72%) were eventually transplanted in 11 days (IQR 3–38 days) using a local (50%), regional (50%) or national (<1%) liver; 60 (21%) died, 13 (4.5%) remained on the waitlist and nine (3.1%) were removed for other reasons. Of those eventually transplanted, MELD score did not increase in 57%; it increased by 1–3 points in 37% and by ≥4 points in 5.7% after the export. In three cases, OPOs exchanged regional exports within a 24‐h window. The majority of comparable reprioritized candidates were not disadvantaged; however, 21% died after an export.