Introduction: Histological evaluation of a potential donor liver can provide useful information prior to liver transplantation (LT) and potentially reduce discard rates. However, the use of a liver biopsy (LB) is not standardized across Organ Procurement Organizations.  On February 4, 2020, the LT allocation policy in the United States changed, likely shifting institutional and regional behavior changes for the acceptance of donated organs.  We sought to review LB utilization patterns before and after the institution of the acuity circle allocation system (ACAS) and determine if LB rates were associated with allograft discard rates, patient and graft survival.

Methods: Data from the Scientific Registry of Transplant Recipients (SRTR) were analyzed on the utilization of LB before and after the implementation of ACAS.  Era 1 was defined as January 1, 2018 to February 3, 2020; Era 2 was defined as February 4, 2020 to June 1, 2021.  Statistical comparisons between eras were performed. Univariable and multivariable models were constructed to determine donor characteristics that were correlated with obtaining a LB during the eras. Kaplan-Meier survival analysis was performed to determine the impact of LB on patient and graft survival.

Results: We analyzed 29,905 liver transplants performed from January 1, 2018 to June 1, 2021; 17,949 (60%) were performed in Era 1 and 11,956 (40%) were performed in Era 2.  During the study time period, there were 11,043 LB performed; 6,488 (58.8%) in Era 1 and 4,555 (41.2%) in Era 2 (p<0.001).  Era 1 demonstrated a LB rate of 36.1% while Era 2 demonstrated a LB rate of 38.1% (p<0.001). Donor characteristics associated with obtaining a LB were BMI, race, age, history of DM, and era.  The discard rate between Era 1 (15.8%) and Era 2 (15.0%) did not differ (p=0.097). The 1- and 3-year patient survival for LT recipients was 93.3% and 83.5%, resp., and graft survival during Era 1 was 96.7% and 94.4%, respectively. The 1-year patient survival for LT recipients during Era 2 was 89.9% and graft survival was 96.1%.

Conclusion: The institution of the ACAS led to differing acceptance practices around liver transplantation.  In the time period after institution of the model, there was a statistically significant increase in utilization of LB, likely due to wider catchment areas for potential recipients. ACAS seemed to have no effect on the rates of allograft discard rates, patient, or graft survival.