LAUSR

Like every country, France is facing an ongoing organ shortage and various solutions to overcome this problem are continuously being evaluated. Among these, a simple and effective way to increase the pool of grafts is to expand donor criteria. Numerous studies have emphasized the encouraging results of liver transplantation using so-called marginal grafts provided adequate donor–recipient matching has been secured [1]. In the French allocation system for liver transplantation, standard allocation patients are prioritized according to the ‘‘liver score,’’ which ranges from 0 to 1000 by taking into account MELD score and by providing additional points based on time on the waiting list to selected patients, such as patients with transplantable HCC and low AFP score [2]. While this system respects the universal principle of ‘‘sickest first,’’ patients with marginal indication for liver transplantation, namely those with borderline transplantable HCC (beyond Milan criteria or high AFP score), never make it to the top of the list and are often only offered grafts, which have been denied for top-listed patients. ‘‘Hors tour’’ liver grafts account for these rescue allocation grafts, which have been first refused by the first five teams on the national waiting list and to a lesser extent by surrounding centers for the following patients on the list. When this situation occurs, grafts are then proposed ‘‘hors tour,’’ the choice of the recipient being at the team’s discretion. The rationale of this approach is to offer the possibility to provide ‘‘second hand’’ yet transplantable liver grafts to patients with low liver score and good general status. In the present study [3], Azoulay et al. confirm previously reported good long-term results using these rescue allocation liver grafts [4] but also highlight similar immediate operative courses as those transplanted using standard allocation grafts. By doing so, the authors emphasize that the use of these grafts may allow expanding the pool of donor by 25% without compromising recipient outcomes provided stringent selection of the recipients. While such simple and pragmatic strategy seems appealing at first sight, several questions regarding the current relevance of such approach should be raised. In this study, the 75% initial refusal rate related to mixed medical and logistical reasons raises the question of the definition of the actual marginality of such grafts. Naturally, ‘‘hors tour’’ liver grafts partly share usual characteristics of extended donor criteria grafts as reflected by the reported higher donor risk index than standard allocation grafts. Yet, considering a graft simply based on allocation refusal rather than on exclusive inherent characteristics may also lead to confusing true marginality from a medical perspective and marginality from a supply and demand basis. Hence, while this original approach provides an always updated and pragmatic picture of the selection process of liver grafts, it can be assumed that any increase in graft availability is likely to mechanically transform & François Cauchy [email protected]