Extended Criteria Donors (ECD)

Medically reviewed by James F. Trotter, MD and Joseph S. Redman, MD, PhD, National Friends Medical Advisory Board · Last reviewed October 1, 2026

Extended criteria donor (ECD) livers fall outside the old "ideal donor" profile but can still work well. Here is what that means for your wait and risk.

Extended Criteria Donor (ECD) is a clinical term for donor livers that fall outside the historical "ideal" donor profile but are still suitable for transplant in the right setting. You may also hear "marginal" or "high-risk" donor. There is no single national definition for livers — each program sets its own protocols for which of these livers it will use. ECD criteria typically include:

Older donor age (the cutoff varies by program; many use 60 or 70)
Donors with certain infections that can now be prevented or treated in the recipient (e.g., hepatitis C, hepatitis B core antibody positive, and HIV for recipients who also have HIV under the HOPE Act)
Donors with steatosis (fatty liver) within defined limits
Donors with longer cold ischemia time (more hours on ice before transplant)
DCD donors (donation after circulatory death) — see our article on DCD vs. brain-death donors

Why ECD matters for caregivers

Programs that use ECD livers thoughtfully may be able to offer transplants sooner, which can mean less time on the waitlist.
The trade-off is a slightly different post-transplant risk profile, which the center should explain in your evaluation.
Centers without an active ECD program decline these livers, which can lengthen the wait without necessarily improving outcomes.

The livers are not set aside for anyone special. An ECD liver is offered in the normal order, based on MELD score, blood type, size and distance. The difference is whether your center says yes when it comes up for you. This is one reason the median MELD at transplant differs between centers.

What national data shows

The OPTN/SRTR 2023 Annual Data Report tracks how often recovered livers end up not being used. Some ECD types are turned down far more often:

Older donors: 12.4% of livers from donors aged 55 or older went unused, compared with 3.2% from donors under 18.
Fatty livers: 48.7% of livers with 31% fat or more went unused, and 18.2% of livers with 11% to under 31% fat.
Hepatitis C: 8.8% of deceased liver donors in 2023 had hepatitis C antibodies. Livers from donors with active virus in the blood (NAT-positive) went unused 14.6% of the time. Livers from donors who had antibodies but no active virus were used at about the same rate as livers from donors with no hepatitis C at all (9.2% vs. 9.5% unused).
Public Health Service "risk factor" donors (donors with certain behaviors that raise the chance of a recent infection) were not less likely to be used than other donors.

The same report notes that record transplant numbers in 2023 were driven partly by more livers from older donors and DCD donors, likely helped by machine perfusion. Devices such as HOPE and NMP let teams protect and test some of these livers before transplant. A large European study of HOPE-treated livers from brain-death donors found good long-term graft survival even when the donor livers were older.

Infected-donor livers, explained simply

Many centers run dedicated protocols for hep C-positive and hep B core antibody-positive donors with antiviral coverage. Ask the coordinator whether your center accepts these and what the post-transplant antiviral plan is.

Hepatitis C-positive donor: Modern hepatitis C pills cure most people. If you get a liver from a donor with active hepatitis C, you will likely get the virus, and then the team treats it after transplant. In one small early study, all 10 recipients who got hepatitis C from their donor liver were cured with treatment. Ask when treatment starts and who pays for the medicine.
Hepatitis B core antibody-positive donor: The donor was exposed to hepatitis B in the past. The recipient usually takes a medicine to prevent hepatitis B from coming back, often long-term.
HIV-positive donor: Under the HIV Organ Policy Equity (HOPE) Act, these livers can only go to recipients who also have HIV. As of July 2021, 87 liver transplants had been done within HOPE research studies in the U.S.

Programs usually ask for your specific consent before you can receive most of these livers. You can say yes to some types and no to others. Talk to your team first — saying no can mean fewer offers.

Questions to ask your transplant team

"Which kinds of extended criteria livers does your program accept?"
"Would you consider an older donor liver, a fatty liver or a DCD liver for me?"
"Do you accept hepatitis C-positive or hepatitis B core antibody-positive donors? What is the treatment plan after?"
"Do you use machine perfusion to test these livers before transplant?"
"If I decline certain donor types, how much could that lengthen my wait?"

Common misconceptions

"A 'high-risk' liver means I'll get sick from it." The label usually describes a chance of a problem, often one that can be prevented or treated. Ask for the actual numbers for your situation.
"Holding out for a perfect liver is the safest choice." Waiting has risks too, especially as liver disease gets worse. See understanding your risk.
"All centers use the same rules." They don't. Protocols are center-specific, which is why comparing programs with our center comparison map and considering dual listing can matter.

Sources

Educational only. Not medical advice. Your transplant team has the final word.

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