ISHLT Response to OPTN Modify Effect of Acceptance Policy

Published 19 March 2024

• OPTN Comment

The International Society for Heart and Lung Transplantation (ISHLT) appreciates the opportunity to comment on the policy proposal "Modify Effect of Acceptance Policy." ISHLT recognizes the goal of this policy, to provide additional clarity for OPOs in ensuring procedural alignment and promoting consistency across various organizations in different regions across the country. In general, ISHLT believes this is a reasonable step to take to clarify the MOT policy. Additionally, we acknowledge prioritizing the acceptance of an organ takes precedence over the obligation to offer more than one organ to a single candidate. However, we express some concerns about the policy.

Introducing specific time frames and elements in the policy language could disadvantage heart and lung organs, which potentially have a higher waitlist mortality. We would encourage creating the opportunity for a conversation between transplant centers to allow for MOT if a heart or lung transplant MOT is allocated a thoracic organ but not eligible to receive the donor kidney due to this policy. It is notable that thoracic organs can have difficult to match recipients (small chest cavity, high cPRA), such that all potential donors for a hard to match MOT should be considered.

Additionally, a significant concern is the potential for misuse if an isolated organ is allocated outside the current policy. ISHLT recommends modifying the policy language explicitly to restrict such situations to instances when the OPO has fully followed policy 5.10 (and related organ-specific policies) for prioritizing MOT allocation. This precautionary measure aims to maintain the integrity of the allocation process and prevent unintended deviations from established policies.

ISHLT strongly recommends the OPTN monitor these specific situations where the MOT is bypassed due to one organ having been placed. Notably, where the MOT involves a thoracic organ, this policy could lead to higher waitlist mortality of MOT candidates. We would recommend monitoring MOT waitlist mortality for heart and/or lung transplant candidates separately from MOT that involve only non-thoracic transplants.

In summary, ISHLT remains committed to promoting equitable and ethical organ allocation practices that prioritize the health of all eligible transplant candidates. We believe this policy will impact only a small number of recipients and, as such, we believe the policy is acceptable. We recommend close monitoring when these situations arise and the waitlist outcomes of MOT candidates.