Resources

Published 19 March 2025

• OPTN Comment

The International Society of Heart and Lung Transplant (ISHLT) welcomes the opportunity to comment on the OPTN policy proposal, “Establish Comprehensive Multi-Organ Allocation Policy.” The ISHLT supports standardization and transparency for placement of donor organs. The Multi-Organ Transplantation Committee (MOT) has drafted a highly complex proposal utilizing individual tables assigning multi-organ candidate priority of organ allocation from six different categories of donors.

Feedback from organ procurement organization (OPO) front line workers will be key to anticipating barriers to operationalization and implementation. Currently, the absence of a standardized multi-organ allocation framework leads to inconsistent allocation which may disadvantage certain patient populations. Standardization can ensure equitable access while optimizing organ utilization. The final goal of developing an integrated multi-organ match run would be highly desirable. We understand that the OPTN computer system will be programmed to guide OPO coordinators through the complicated allocation scenarios. We suggest utilizing the OPTN computer system to adapt to real-time logistical challenges, such as last-minute donor status changes, recipient cancellations, or unexpected organ quality issues. We also would consider utilizing the computer system to determine allocation priorities for organs from the 4% of donors not covered by the six tables.

The Ad Hoc MOT utilized a prior values exercise to help determine the order of priority among different organ groups. We agree with the recommendation that all other organs follow the primary organ on the heart, lung, and liver matches. This approach is largely consistent with current practice and should continue. Although we mostly agree with the rankings in the allocation tables, we question the placement of pre-sensitized pancreas/kidney-pancreas candidates above status 3 heart-kidney candidates. We recommend reassessment after analysis of post-implementation data. We also believe that the waitlist survival data in table 5-1 is difficult to interpret. For example, the median estimated risk for 1-year survival pretransplant of status 1a liver transplant candidates is given as 94.3%. We know that OPTN policy requires an expected survival of less than 7 days for this group, and published data suggests a median survival of at least 24 days (Wood et al., AJT 2022 Vol 22(1): 274-8). The committee may wish to clarify these apparent discrepancies and provide further justification for this prioritization, particularly if the decision to place status 1A multiorgan liver candidates first was based on assumptions that candidates in this group uniformly have a waiting list survival of less than 7 days.

As lung transplant allocation has undergone major changes with CAS, the interaction between CAS-based prioritization and multi-organ allocation should be closely monitored. We recommend the use of CAS percentiles rather than absolute scores to accommodate changes in waitlist composition in the future. Additionally, as medical urgency and access to transplant are the most common justifications for placement of other organs on the lists, the OPTN should consider utilizing only the medical urgency and access to transplant components of the CAS score to create equivalency and revise the tables once all organs have implemented CAS scores incorporating both pre- and post-transplant survival estimates.

Finally, the proposal does not clearly account for the differences in organs transplanted per donor for each organ – a donor is roughly twice as likely to yield a transplanted liver than a heart or a pair of lungs. This may disadvantage heart-lung, heart-kidney and lung-kidney candidates in comparison to liver multiorgan candidates. Simulation modeling and post-implementation evaluation should be performed to provide reassurance that this factor does not lead to inequitable access for heart and lung candidates. This will impact equitable access to multi-organ transplant and should be considered in the model. The ISHLT wants to ensure that the implementation of this multi-organ allocation policy does not have unintended consequences on heart and lung recipients and would like to emphasize the importance of post-implementation data collection. Simulation modeling should be performed to anticipate potential consequences.