ISHLT Response to OPTN Promote Efficiency of Lung Allocation Policy

Published 19 March 2024

• Advanced Lung Failure & Transplantation
• Cardiothoracic Surgery
• OPTN Comment

The International Society for Heart and Lung Transplantation (ISHLT) appreciates the opportunity to comment on the policy proposal "Promote Efficiency of Lung Allocation."

The continuous distribution system appears to have advanced progress in lung allocation by reducing waitlist mortality and improved access for the most urgent candidates. However, as a result, organ offer patterns have shifted with increases in travel distance, median number of transplant centers and offer numbers at acceptance. To improve allocation efficiency, OPTN plans to incorporate lung offer filters and new data collection within the Donor Data and Matching System in early 2024 with the goal to assist programs in managing offer volume and improve allocation efficiency for OPOs. While this policy should be supported, ISHLT provides some comments for consideration:

Regarding the new data fields:

1. The “history of anaphylaxis to peanut and/or tree nut” field is of concern. Because it is a rare event, it has the potential to be marked positive in circumstances where risk of donor transmission of anaphylaxis would be low and may lead to discarding usable organs. If this field is added, there should be an option for yes, no, or unknown.
2. There should be consideration of adding previous thoracotomies as well as sternotomies as data fields.

Regarding additional filters:

1. There is an anticipated need to expand this feature to make additional criteria available for filtering.
2. There is great enthusiasm for increased flexibility including the option to combine filters to enhance efficiency. For example, including the ability to filters donors by sex + height separately for male and female donors.
3. Filtering that is too restrictive, for example applying to an entire program, could ultimately decrease the utilization of organs, as some offers will be filtered out that would otherwise have been accepted if the center reviewed the offer in more detail.
4. Ideally, filtering would expand in the future to be optional on an individual level.
5. The policy of “bypass bilateral and other” is considered reasonable.
6. It may be important to incorporate candidate education and perspective on offer filters as they are expanded in the future.

Regarding efficiency:

1. Currently, for high score CAS candidates, the odds of getting a better offer with time are good, which contributes to inefficiency.
2. There is support for adopting limitations on the number of sequential offers made by OPOs.
3. The cost/benefit of opting into geographically isolated areas will need to be considered on a program-specific level.
4. Patients and families would likely support efforts to improve efficiency. Because this process affects candidates, there should be educational information made available in a form that can be understood by the general public.