Truncated Acuity Circles: Coastal and Border Centers

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

Donor livers are offered within circles drawn around the donor hospital. Near an ocean or the Canadian border, part of each circle has no donors at all.

How livers are offered today: acuity circles

Since February 2020, the U.S. offers donor livers using acuity circles, not regions or donor service areas (Wood et al., 2021). Three circles are drawn around the donor hospital: 150, 250, and 500 nautical miles. Each liver is offered first to the most urgent patients whose transplant center sits inside those circles, and then outward to a national list.

Your urgency is measured by your MELD score (PELD for young children). Since July 2023, adults are scored with MELD 3.0 (Hepatology, 2026). So two things decide where a liver goes: how sick the patient is, and how far the patient's transplant center is from the donor hospital.

You may still read older advice about "your region" or "your local donor area." That advice is out of date for livers. Regions no longer decide who is offered a liver.

What "truncated" means

Acuity circles are the same size everywhere in the country. Researchers have pointed out that fixed-size circles do not account for differences in population, or for being close to a coast or a national border (Wood et al., 2021).

Picture a 250-mile circle drawn around a donor hospital in the middle of the country. The whole circle is land, with towns, hospitals, and potential donors in every direction. Now draw the same circle around a donor hospital on the coast. Part of that circle is ocean. Part of a circle drawn near the northern border is in Canada, where U.S. donors are not found. The circle is truncated: it is the same size on the map, but it holds fewer donor hospitals.

The same thing works in the other direction. A transplant center in the middle of the country sits inside the circles of donor hospitals on every side. A center on a coast or near the border has donor hospitals on only one or two sides, so fewer donor hospitals have that center inside their circles.

Where this matters most

These places are examples of geography that cuts circles short. They are not allocation zones:

New England and the Northeast coast. The Atlantic Ocean is to the east and Canada to the north.
The Pacific Northwest. The Pacific Ocean is to the west and Canada to the north, with large lightly populated inland areas.
Florida and the Gulf Coast. Water lies on several sides.
Hawaii, Alaska, and Puerto Rico. These are far from the mainland. A circle drawn around a mainland donor hospital does not reach them, so patients there depend on local donors and on livers offered after the circles are exhausted.

What it does and does not mean for you

A truncated circle is one factor, not a verdict. It does not mean every coastal or border center has long waits. Waits also depend on:

how many people donate locally,
how many patients are listed at nearby centers,
whether a program accepts livers from farther away, and
whether a program uses livers from DCD and extended-criteria donors (see DCD vs. brain-death donors and extended criteria donors).

Check your own program's numbers in its SRTR report (SRTR). You can also compare the median MELD at transplant near each center, and typical waits by center on our liver waiting list guide.

What caregivers can do

Look at where a second center's circles reach. If your center has long waits, dual listing at a center in a different part of the country is worth discussing. A second center gets offers from the donor hospitals around it, so a center whose circles cover more populated land may see different offers.
Listing in a different area helps more than listing nearby. SRTR's patient guidance says candidates who list in different areas may benefit more than candidates who list at several centers in the same area (SRTR FAQ for patients).
Plan the practical side. Dual listing needs a full evaluation at the second center, your insurance's approval, and a travel plan for when a liver is offered. Our dual-listing guide walks through the steps.
Know what the research shows, and its limits. In a national study of more than 100,000 waitlist registrations, patients who listed at a distant center far from home had a 22% lower risk of dying within a year (Kwong et al., 2019). That study covered 2004 to 2016, before acuity circles began, so results today may differ.

Questions to ask your transplant team

"Roughly what MELD score are patients with my blood type transplanted at here?"
"Does your program accept livers from donor hospitals farther away?"
"Does your program use DCD or extended-criteria livers?"
"Would listing at a second center help me, given where its donor circles reach?"
"If I list elsewhere, can my local team keep managing my care while I wait?"
"How quickly would I need to get to the other center if a liver were offered?"

Common misconceptions

"My region decides who gets livers." Not since February 2020. Medical urgency and distance from the donor hospital decide.
"Listing in another region gives me that region's livers." There are no regional pools of livers. A liver is offered to patients at centers inside the circles around that donor hospital, so what matters is where the second center sits on the map.
"Everyone near a coast or border waits longer." Not necessarily. Waits differ a lot from center to center. Look at program-level data.
"Acuity circles removed geography from allocation." Distance is still part of every offer. Fixed-size circles also mean coasts and borders still change how many donor hospitals are within reach.

You can find programs near you, and farther away, in our transplant center directory.

Sources

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

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