Change in Organ Allocation Designed to Increase Equity in US Kidney and Pancreas Transplantation

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Earlier this year, the United Network for Organ Sharing (UNOS) introduced new kidney and pancreas allocation policies intended to increase equity in kidney and pancreas transplant access across the United States.

A History of Good Intentions

Organ allocation in the US has long existed in the wake of practical and administrative disparities. Perhaps the lead among these is the decades-long imbalance between the number of candidates for organ transplantation and the availability of suitable donor organs. A close second, however, might be the discord between the many well-intentioned initiatives to serve the transplant population — and the general disappointment with these efforts, to date, in this community.

In the 1970s, the needs of the transplant community spurred an effort by constituent organizations, clinicians and governmental bodies to find better ways to coordinate and allocate organ distribution. With time, however, these efforts in good will became mired in issues of need and utility. To address the discord and complications that ensued, the National Organ Transplant Act of 1984 established the Organ Procurement and Transplantation Network, a nationwide system in the private sector. Soon afterward, UNOS and others in the transplant community developed a framework for organ allocation that would, among other goals, strike a balance between the needs of the sickest patients and the efficient use of organs.

A System for Organ Allocation

US organ procurement organizations - little location icons on a map

To coordinate and increase the efficiency and equity of organ allocation, the new system established geographical donation service areas (DSAs). Within these areas, synonymous organ procurement organizations (OPOs) were established to assess donor potential, collect and convey accurate clinical information, and recover organs from deceased donors for transplantation. There are now 57 OPOs within 11 regions in the United States, including the Gift of Life Donor Program that represents the Philadelphia region. Each service area also contains one or more transplant centers with the responsibility of reviewing organ offers from the OPOs for suitability for their patients.

Until recently, the allocation of organs began at the transplant centers within an OPO, where the offer of an available organ was first be made to the sickest candidates listed. If no patient with an urgent medical need was available, the organ was next offered to patients in the same OPO with less medically urgent conditions. Finding no suitable patient within the local OPO, the organ could then be offered at the regional, and finally, the national level.

But even the enhanced and improved system failed to meet the needs of the community it was designed to serve.

"A big problem with this approach was simple geography," says Penn transplant surgeon Ty B. Dunn, MD, MS, Surgical Director of the Penn Kidney and Pancreas Transplant Program. Location was especially an issue when a candidate was listed at a transplant center located on the other side of a boundary between OPO's. This was an issue, Dr. Dunn observes, because an adjacent OPO might have a shorter waiting time, which meant the artificial boundary of the donor service area prevented access to donors close by.

"Geographic boundaries can also be problematic when OPOs contain disparate levels of organ availability and donor registrations," Dr. Dunn adds. "Within OPOs in different areas of the country, we find different rates of death from causes that can drive organ donation (strokes, accidents, and opioid overdoses for example) and differences in access to health care that can impact the likelihood of getting on a waitlist."

The definition of waiting time was perhaps the most contentious issue affecting fairness of the older system of kidney allocation. It used to be that the waiting time started when a patient was listed for transplant, regardless of when they met the qualifying criteria (date of dialysis start or GFR 20 ml/min or less). Under the old system, patients referred for transplant after many years of dialysis did not get credit for time spent on dialysis prior to listing. With the more recent updates to the allocation system, the date of wait time is applied retroactively as the date that dialysis began, or if not on dialysis, when they met the qualifying GFR of 20 ml/min or less and were listed. This was a huge benefit to candidates who experience health disparities and inequities in access to care, a first step in leveling the playing field for those seeking a scarce resource.

Multi-listing can exacerbate organ allocation by allowing some, but not all, candidates within an OPO to benefit from access to organs outside of a designated OPO. Dependent upon access to amenable insurance and the wherewithal to travel, multi-listing emphasizes the socioeconomic disparity ingrained in the system, particularly when it involves OPOs belonging to different regions. All of the above, Dr. Dunn observes, collide to create vast inequity and disparities in organ allocation.

A Case Study in Kidney Organ Allocation

In 2017, Mr. W, a 37-year-old man with advanced kidney disease and type O blood type was wait-listed for a kidney in Philadelphia and told it would take between 6 to 8 years to make it to the top of the local list. At the same time, Mr. W's former neighbor, Mrs. J, was living in New York, where the average wait for a kidney is 8 to 10 years. A 49-year-old candidate for kidney transplantation, Mrs. J was able to increase her chances of obtaining a kidney by multi-listing in Philadelphia and other areas with shorter waiting times in hopes of getting an earlier transplant. She was able to do this because she had the insurance and the wherewithal to travel to different centers for evaluation and potentially a kidney, should one become available. Mr. W, by comparison, could not multi-list because he lost his insurance when he was no longer able to work, and was home-bound.

The Issue: Organ Allocation Disparities

To remove artificial boundaries of geography, the US Department of Health and Human Services (DHHS) introduced a new regulation in 1998 that established that, allocation policies should not be based on a candidate's place of residence or place of listing.

Efforts to reform the organ allocation system continued through the 2000s, but as recently as five years ago, the place of listing remained the principal factor in transplantation rates. Addressing the issue in March 2021, UNOS launched a new system that eliminated the use of DSAs and regions from kidney and pancreas distribution.

"Under the new system, kidney and pancreas offers (except for rare, very well-matched donor and recipient combinations nationwide) will be offered first to candidates listed at transplant hospitals within 250 nautical miles of a donor hospital," Dr. Dunn explains. "If the organs aren't accepted by any candidates within the 250 nautical mile radius, they'll be made available to candidates beyond the 250 nautical mile distance. This essentially makes these organs available nationwide."

Nautical miles are slightly longer than land miles and are the standard for air travel — thus 250 NMs is equal to 287.7 land miles. Candidates also will receive proximity points based on the distance between their transplant program and the donor hospital. Proximity points are intended to improve the efficiency of organ placement by adding priority for candidates closer to the donor hospital. The point assignment will be highest for those closest to the donor hospital and will decrease as the distance increases.

Under the new system, multi-listing is still a possibility, but the expansion of the former artificial boundaries of geography to 250 NMs will diminish the value of multi-listing at programs in close proximity, since any priority obtained will be much the same among transplant hospitals within this range.

Adding to the Benefit of Greater Access

All of the advantages of the new UNOS system should help overcome disparities in organ availability and allocation. However, according to Dr. Dunn, the greatest benefit to individual candidates remains an integral relationship with the home transplant center.

"It's very important that patients list at a center that they trust," says Dr. Dunn. "This is something we work very hard to achieve at the Penn Transplant Institute, because we know that post-transplant success depends on being able to have proper follow-up, and this can only happen when there is easy interaction between clinicians and support staff."

Penn is unique in having access to two transplant houses (the Clyde Barker House near the Penn campus, and the Gift of Life Family House in Philadelphia) that offer discounted rates and a supportive community to patients and their care partners before and after transplant.

"This is most important to avoid a stressful early post-transplant experience when patients may not feel well enough to travel or find it financially burdensome to remain close to the transplant center," Dr. Dunn concludes.

About the Penn Transplant Kidney and Pancreas Transplant Program

A long-time proponent of the equitable allocation of organs for transplant, the Penn Transplant Institute offers many unique services for transplant candidates in addition to the aforementioned transplant houses in the city of Philadelphia, including:

  • One of the region's largest living donor programs;
  • Access to multi-organ transplantation and kidney paired exchange;
  • A thriving research program: Penn was among the first transplant centers to transplant hepatitis C-infected kidneys into non-infected recipients, who were then cured of the disease by antiviral therapy;
  • A focus on patient safety: the Penn Transplant Institute has offered COVID-19 guidelines for transplant patients, including booster vaccine recommendations.

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