LAUSR

One of the crucial objectives in medicine is to assess and quantify the benefit of a therapeutic approach to a given clinical condition in order to avoid delivering potentially harmful treatments (when the risk is greater with than without the therapy) or wasting resources (when the benefits are insignificant). This becomes particularly important when the resource in question is in short supply, as in organ transplantation, where complex ethical principles relating to equity, justice, utility, autonomy, beneficence, nonmaleficence, and benefit make resource allocation extremely challenging. In the transplantation setting, negative outcomes can occur in patients on the waiting list or after they have received a transplant. Organ allocation for liver transplantation (LT) in decompensated cirrhosis has historically focused on the waiting list phase, adopting “urgency” predictors—the Model for End-Stage Liver Disease (MELD) and its derivatives—to reduce the pre-LT mortality risk (the “sickest first” approach). But this policy fails to consider that the sickest patients may have a worse posttransplant outcome, and this reduces the overall benefit of the procedure. At the same time, this approach does not prevent some patients with low MELD scores from being transplanted despite their risk of dying being higher with a transplant than without one (the transplant does more harm than good). The crucial issue of the benefit of LT emerged from the seminal observations of Schaubel et al. Transplant benefit (TB) can be defined as the net survival obtained by subtracting the survival obtainable with nontransplantation options from the expected survival achieved with LT (ideally from the time of listing). TB reflects the main factors (urgency and utility) throughout the clinical process—not only waiting list priorities but also donor–recipient matching, recipient surgery, and posttransplant management. Schaubel et al. referred to benefit not only as a transplant selection principle (to prevent patients potentially harmed by a transplant from being placed on the waiting list) but also as an allocation principle, proposing a “benefit score calculation” based on the United Network for Organ Sharing waiting list/transplanted series. This calculator has yet to be validated, however. In an ideal scenario where transplants are allocated by benefit, the limited donor resources are given neither to patients on the waiting list with the shortest expected survival (urgency) nor to those with the longest expected posttransplant survival (posttransplant utility) but to those with the greatest difference between the two. This would optimize the total life-