UNMC study shows need to re-examine organ transplant allocation

by Vicky Cerino
June 24, 2021

Image with caption: Scott


Multi-organ transplantation -- simultaneously transplanting a kidney with another organ such as a liver or heart -- has increased substantially over the past two decades. The reason: a changing population of transplant candidates and modifications to organ allocation policies.
Multi-organ transplant (MOT) candidates receive organ allocation priority above those who need a kidney-alone transplant (KAT). Because of a national organ shortage, the increase in MOT use -- along with higher allocation priority -- puts KAT candidates at a disadvantage.
Nationally, more than 90,000 patients are on the waiting list for a kidney.
UNMC researchers published a study in the June print issue of the American Journal of Transplantation (the study appeared online in the journal in November) that makes a case for changes in the nationwide organ allocation process.
"The transplant community continues to grapple with the increased MOT utilization and allocation policy," said Scott Westphal, MD, University of Nebraska Medical Center assistant professor of internal medicine, Division of Nephrology and first author of the article. "I am hopeful this paper will help inform the national discussion on MOT policy and help guide future policy development."
The study, funded by the department of internal medicine, evaluated the impact of the current multi-organ transplant allocation policy on KAT candidates. Researchers used a large Organ Procurement and Transplantation Network database from 2002-2017 to identify 7,378 KAT next-sequential candidates (those who would have received a given deceased donor kidney had it not been offered first to a higher prioritized MOT recipient).
"Despite receiving higher priority, MOT candidates had spent significantly shorter time on the waiting list, were less likely to be receiving dialysis, and had better kidney function than next-sequential candidates," Dr. Westphal said. "Next-sequential candidates were younger and more likely to be from a racial/ethnic minority group, highlighting the potential for MOT to exacerbate disparities in already disadvantaged groups." 
Dr. Westphal said after missing out on a potential organ allocation offer, 2,113 (28.6%) of next-sequential KAT candidates either died on the waiting list or were removed from the list without receiving a transplant. The researchers also found a 55% increased risk in death in the next-sequential candidates compared to the KAT candidates who received the given kidney offer.
"As the field of transplantation has evolved, MOT has emerged as a potentially lifesaving option for some patients who may otherwise not survive," Dr. Westphal said. "However, in an era of profound shortage of donor organs, the increased use of kidneys for MOT may come at the expense of outcomes for KAT candidates."
Co-authors of the study are Eric Langewisch, MD, Jianghu Dong, PhD, Troy Plumb, MD, Ryan Mullane, DO,Clifford Miles, MD, Alex Maskin, MD, Shaheed Merani, MD, PhD and Arika Hoffman, MD.

An editorial and a letter to the journal editor from other medical centers supports discuss the complex challenges of multi-organ allocation policy and the notion that current policy and missed/declined organ offers have negative consequences to kidney-alone transplant candidates.