David S. Goldberg, Matthew Levine, Seth Karp, Richard Gilroy, Peter L. Abt

Share 35 was implemented to provide improved access to organs for patients with MELD scores ≥35. However, little is known about the impact of Share 35 on organ offer acceptance rates. We evaluated all liver offers to adult patients that were ultimately transplanted between 1/1/2011-12/31/2015. The analyses focused on patients ranked in the top five positions of a given match run, and used multi-level mixed-effects models, clustering on individual waitlist candidate and transplant center. There was a significant interaction between Share 35 era and MELD category (p<0.001). Comparing offers to MELD score ≥35 patients, offers post-Share 35 were 36% less likely to be accepted compared to offers to MELD score ≥35 patients pre-Share 35 (adjusted OR: 0.64). There was no clinically meaningful difference in the DRI of livers that were declined for patients with an allocation MELD score ≥35 in the pre- vs post-Share 35 era. Organ offer acceptance rates for patients with an allocation MELD≥35 decreased in every region post-Share 35; the magnitude of these changes was bigger in regions 2, 3, 4, 5, 6, 7, and 11, compared to regions 8 and 9 that had regional sharing in place pre-Share 35. There were significant changes in organ offer acceptance rates at the center level pre- vs post-Share 35, and these changes varied across centers (p<0.001). In liver transplant candidates achieving a MELD score ≥35, liver acceptance of offers declined significantly after implementation of Share 35. The alterations in behavior at the center level suggest that practice patterns changed as a direct result of Share 35. Changes in organ acceptance under even broader organ sharing (redistricting) would likely be even greater, posing major logistical and operational challenges, while potentially increasing discard rates, thus decreasing the total number of transplant nationally. This article is protected by copyright. All rights reserved.