Abstract
Purpose of Review
Since the creation of the Organ Procurement and Transplantation Network (OPTN), the allocation of deceased donated organs for transplantation has been guided by the principles of equity, fairness, and utility. Each individual organ has a well-designed policy which generates a list of eligible potential recipients, with a clearly defined prioritization based on their points. While this system works for single organ transplants, there is an increasing incidence of situations where more than one organ is requested for the recipient.
Recent Findings
These multi-organ transplants (MOTs) are being performed with increasing frequency, and now exceed 2000 cases annually, comprising over 4000 of all organs transplanted. Although some organ combinations, heart–lung and pancreas-kidney, have policy-defined listing criteria and others, liver-kidney, have specific medical criteria, there are multiple considerations regarding the ability more urgent or lifesaving organ being able to “pull” the immediately non-lifesaving organ (most frequently the kidney). Currently, the candidates awaiting a kidney transplant alone have limited opportunity to be stratified for a kidney until the MOT candidates are considered, even to the exclusion of the very highly sensitized candidate. In recent analysis, the majority of kidneys utilized in MOT are those with the greatest potential post-transplant lifespan, which should have been primarily prioritized to the pediatric candidates.
Summary
We examine the history of MOT and current efforts within the OPTN to address the potential for modification to promote the principles of equity, fairness, and utility. Specific issues were examined, including the prioritization of MOT recipients for the “pulled” organs, the effects on the pediatric kidney waitlist candidates, the data and risk stratification of the MOT recipients as part of the center’s Program-Specific Report, and the use of accepted medical criteria, to raise the questions as to how the current policies are comprehensively reevaluated. The need for nationally accepted definitions and criteria within each organ group should be established so as to serve as a common framework for the continuous distribution models currently being proposed. We provide an algorithm for initiating this discussion, with definitions and responsibilities, and the need to encompass all considerations of every organ, including previously OPTN policy–defined combinations, to serve as a discussion template for further dialogue.
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Abbreviations
- DSA:
-
Donor service area
- EPTS:
-
Estimated Post-Transplant Survival
- HRSA:
-
Health Resources and Services Administration
- Ht-Lg:
-
Simultaneous heart–lung transplant
- KDPI:
-
Kidney Donor Profile Index
- KOT:
-
Kidney only transplant
- MELD:
-
Model for end-stage liver disease
- MO:
-
Multi-organ
- MOT:
-
Multi-organ transplant
- OPO:
-
Organ Procurement Organization
- OPTN:
-
Organ Procurement and Transplantation Network
- PSR:
-
Program-specific report
- SLK:
-
Simultaneous liver-kidney transplant
- SPK:
-
Simultaneous pancreas-kidney transplant
- SRTR:
-
Scientific Registry of Transplant Recipients
- U:
-
Units
- UNOS:
-
United Network for Organ Sharing
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
National Organ Transplant Act (NOTA; P.L. 98–507). 1984. https://www.congress.gov/bill/98th-congress/senate-bill/2048. Last Accessed 11/5/2021.
OPTN/UNOS Data. Organ Procurement and Transplantation Network Website. https://optn.transplant.hrsa.gov/data/. Last accessed 11/5/2021.
Wolf JH, Sulewski JR, Cassuto MH, et al. Simultaneous thoracic and abdominal transplantation: can we justify two organs for one recipient. Am J Transplant. 2013;13(7):1806–16. https://doi.org/10.1111/ajt.12291.
•• Ethics implications of multi-organ transplants: OPTN Ethics Committee White Paper. 2019. This paper is a well-referenced resource of the ethical considerations for the multi-organ process, divided into distinct sections to examine specific characteristics of the current policy. It avoids addressing the issues of pediatric and SPK transplant .https://optn.transplant.hrsa.gov/media/2989/ethics_boardreport_201906.pdf. Last Accessed 11/1/2021.
Westphal SG, Langewisch ED, Robinson AM, et al. The impact of multi-organ transplantation allocation priority on wait-listed kidney candidates. Am J Transplant. 2021;21(6):2161–74. https://doi.org/10.1111/ajt.16390.
OPTN Allocation Policies: 5.10.c: Allocation of multiorgan combinations. . https://optn.transplant.hrsa.gov/media/eavh5bf3/optn_policies.pdf. Last accessed 11–1–21.
OPTN Allocation Policies: Policy 11: Allocation of Pancreas, Kidney-Pancreas and Islets. https://optn.transplant.hrsa.gov/media/eavh5bf3/optn_policies.pdf. Last accessed 11–1–21.
Aeder MI. Simultaneous liver-kidney transplantation: policy update and the road ahead. Curr Transpl Rep. 2018;5:130–8. https://doi.org/10.1007/s40472-018-0190-0.
Simultaneous Liver Kidney Allocation Policy. OPTN/UNOS Kidney Transplantation Committee. https://optn.transplant.hrsa.gov/media/1192/0815-12_slk_allocation.pdf. Last accessed 11/1/2021.
Definition of Pancreas Graft Failure. Pancreas Transplantation Committee, OPTN. 2014. https://optn.transplant.hrsa.gov/media/1572/policynotice_20150701_pancreas.pdf. Last accessed 11/5/2021.
Stegall MD, Stock PG, Andreoni K, Friedewald JJ, Leichtman AB. Why do we have the kidney allocation system we have today? A history of the 2014 kidney allocation system. Hum Immunol. 2017;78(1):4–8. https://doi.org/10.1016/j.humimm.2016.08.008.
• Altshuler PJ, Shah AP, Frank AM, Glorioso J, Dang H, Shaheen O, Patel K, Ramirez CB, Maley WR, Bodzin AS. Simultaneous liver kidney allocation policy and the Safety Net: an early examination of utilization and outcomes in the United States. Transpl Int. 2021;34(6):1052–1064. Published online 2021 May 19. https://doi.org/10.1111/tri.13891.As the first multi-organ combination to have a policy directive defining medical necessity, liver-kidney, this is a review of the early outcomes, gaps, and successes of the policy.
Aeder M, Turgeon N. Multi-organ (M-O) prioritization of kidneys: time for policy modification? [abstract]. https://atcmeetingabstracts.com/abstract/multi-organ-m-o-prioritization-of-kidneys-time-for-policy-modification/. Last accessed 11/5/2021.
2019 Annual Data Report. Scientific Registry of Transplant Recipients. http://srtr.transplant.hrsa.gov/annual_reports/2019_ADR_Preview.aspx. Last accessed 11/5/2021.
Schold JD, Buccini LD, Goldfarb DA, Flechner SM, Poggio ED, Sehgal AR. Association between kidney transplant center performance and the survival benefit of transplantation versus dialysis. Clin J Am Soc Nephrol. 2014;9(10):1773–80. https://doi.org/10.2215/CJN.02380314.
Kaballo MA, Canney M, O’Kelly P, Williams Y, O’Seaghdha CM, Conlon PJ. A comparative analysis of survival of patients on dialysis and after kidney transplantation. Clin Kidney J. 2018;11(3):389–93. https://doi.org/10.1093/ckj/sfx117.
Scientific Registry of Transplant Recipients. https://www.srtr.org/. Last accessed 11/5/21.
Reese PP, Veach RM, Abt PL, Amaral S. Revisiting multiorgan transplantation in the setting of scarcity. Am J Transplant. 2014;14(1):21–6.
OPTN/UNOS Clarify Multi-Organ Allocation Policy – Public Comment Proposal January 2021. https://optn.transplant.hrsa.gov/media/4354/2021_pc_opo_clarify_multi_organ_allocation_policy.pdf. Last Accessed 11.1.2021.
OPTN/UNOS White Paper, Ethical Considerations of Continuous Distribution in Organ Allocation, submitted August 2021. https://optn.transplant.hrsa.gov/media/4778/ethical_considerations_of_continuous_distribution_in_organ_allocation.pdf. Last accessed 11.1.2021.
Stites E, Wiseman AC. Multiorgan transplantation. Transplant Rev. 2016;30(4):253–60. https://doi.org/10.1016/j.trre.2016.04.002.
• Cheng XS, Reese PP. Incorporating kidney related multi-organ transplants into the kidney allocation sequence. Am J Transplant. 2021;21:2614–5. https://doi.org/10.1111/ajt.16542In this relatively short comment, the authors raise key issues for the consideration of the multi-organ stratification process. This is well outlined in the table.
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The authors (MA and KA) do not have any conflicts of interest with regard to the contents of this manuscript. They have no financial relationships to disclose. The above review does not contain any unique studies involving human or animals and represents a summary of the current literature and potential for future directions.
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Aeder, M., A. Andreoni, K. Multi-Organ Allocation: Medical and Ethical Considerations. Curr Transpl Rep 9, 5–11 (2022). https://doi.org/10.1007/s40472-022-00354-5
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DOI: https://doi.org/10.1007/s40472-022-00354-5