Comments

OPTN Ad Hoc Disease Transmission Advisory Committee | 03/20/2024

The Ad Hoc Disease Transmission Advisory Committee (DTAC) thanks the Lung Transplantation Committee for the opportunity to comment on their proposal, Promote Efficiency of Lung Allocation. While peanut/tree nut allergies remain rare, DTAC commends the Committee's effort in assisting lung transplant programs in filtering offers they will not accept by collecting data on the donor history of anaphylaxis to peanut and/or tree nuts. Since 2016, two peanut/tree nut allergy events have been reported to DTAC.

Furthermore, a 2019 study reported literature on allergy transfer upon solid organ transplantation. Based on a review of 577 consecutive deceased donors from the Swiss transplant Donor-Registry, 3 cases (0.5%) of fatal anaphylaxis were identified, 2 because of peanut and 1 of wasp allergy. As early as 5 days post-transplantation, newly acquired peanut-specific IgE were transiently detected from 1 donor to 3 recipients, of whom 1 liver and lung recipient developed grade III anaphylaxis.

Additionally, DTAC acknowledges several challenges associated with this proposal:

§ Allergy to peanut/tree nut is a not a discrete field in the universal Donor Risk Assessment Interview (uDRAI) – this may lead to an opportunity for missed identification

§ Uncertainty around how many donors would be restricted and missed opportunities for transplantation

§ Unknown implication for the recipients

§ How the use of these organs will be successfully managed

The DTAC remains neutral regarding new data collection with a history of anaphylaxis to peanut and /or tree nut, as the prevalence of these allergies in the general population is low, and individuals with anaphylactic reactions represent a smaller subset of that population. 

UC San Diego Health Center for Transplantation | 03/20/2024

UCSD Center for Transplantation (CASD) appreciates the effort the Lung Transplantation Committee put into providing such a detailed community update and their ongoing efforts to solicit public feedback on ways to further promote the efficiency of lung allocation.

While we do not yet feel we have enough experience with the lung offer filters we appreciate that they have been made available as a tool.

With regards to adding new data collection to aid transplant programs in the evaluation of lung offers, we would favor collecting data on prior sternotomies as well as disclosure of donor peanut allergies as we have had 2 cases thus far of donor transmission of the allergy to the recipient, in which the recipient developed anaphylaxis.

Likewise, given our goal to increase donor access to remote regions, we favor the concept of giving programs the option to opt-in to offers from geographically isolated areas (for example: Hawaii, Alaska, Puerto Rico) and allowing OPOs who are placing a single donor lung the option to skip candidates who need a bilateral lung transplant via a new bypass code. The Committee will need to monitor for unintended consequences such as programs modifying their listing practices so as not to "miss out on any offer" including those which would not be appropriate to accept for the candidate in question.

Infinite Legacy | 03/19/2024

Infinite Legacy supports the Lung Transplantation Committee’s recommendation of standardization and any offer filters that can be developed for lung allocation. We agree with previous comments that education surrounding this topic is extremely important, particularly in UNOS Connect.

LifeLink Foundation (FLWC, GALL, PRLL) | 03/19/2024

The OPOs of the LifeLink Foundation (LifeLink of Florida, Georgia, and Puerto Rico) support the lung committee’s efforts to improve efficiencies within the organ transplant system. Use of offer filters continues to be a significant step to ensure the OPOs and transplant centers can maximize technology to enhance the allocation process.

We believe the proposed added filters do not create an undue burden on the OPOs and support the addition of the anaphylaxis criteria. We would recommend a filter for cigarette use based on pack years; data already collected within the OPTN system. The ability to bypass candidates when only a single lung is available is an appropriate and necessary step which will reduce allocations out of sequence and increase use.

As one of the geographically isolated areas named within this proposal, we support this significant step in improving efficiency within the system. We believe the added opt-in method for geographically isolated areas will benefit the OPO and transplant centers to more rapidly allocate lungs (and hopefully future organs) for those centers willing to accept lungs from the island of Puerto Rico.

We strongly ask that the monitoring plan include evaluation of this geographic filter to ensure there are no unintended consequences which could negatively impact the lung utilization from the OPO’s service area.

International Society for Heart and Lung Transplantation | 03/19/2024

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Mid-America Transplant | 03/19/2024

Mid-America Transplant (MT) appreciates the opportunity to provide feedback to the OPTN regarding Efficiency of Lung Allocation. As a high-performing organ procurement organization (OPO), MT is committed to its mission of saving lives through excellence in organ and tissue donation, and we are grateful for OPTN’s efforts to improve efficiency in the organ transplant system.

In our experience, any effort made to increase the likelihood of an organ being transplanted will be well-received by patients and donor families, as donor families want their loved one to be a hero and save more lives.

MT does not anticipate any challenges to reporting the additional donor data. MT obtains a chest x-ray on every potential lung donor and can ask donor families about a potential donor’s allergies without additional burden. The proposed data definitions are easy to understand.

MT supports any system enhancement to increase efficiencies within the system and save more lives. MT encourages the OPTN to explore the use of artificial intelligence (AI) to enhance organ allocation. Currently, the allocation system generates a list of recipients and requires an OPO to allocate through that list until an organ offer is accepted by a transplant center. Too often, an OPO will run out of time to allocate the organ before the recipient list is exhausted. An improved system might include the use of AI to recognize organ acceptance patterns and to adjust the recipient list accordingly, speeding up the process and increasing the likelihood of an organ being transplanted, thereby saving more lives. AI might also assist transplant centers in evaluating organ offers more effectively, improving the efficiency of the overall allocation process.

OPTN Transplant Administrators Committee | 03/19/2024

The OPTN Transplant Administrators Committee appreciates the opportunity to comment on the OPTN Lung Transplantation Committee’s policy proposal, Promote Efficiency in Lung Allocation. The Committee offers the following feedback for consideration.

•Members appreciate the option to select specific geographically isolated areas, such as Hawaii or Puerto Rico, without having to accept organs from all isolated areas.

•In relation to the newly released Lung Offer Filters, it was recommended to add a filter option based on a calculation for total lung capacity. Another recommendation is to include smoking history as a filter variable.

•The Committee advises providing a “reverse” option for when an OPO chooses to bypass bilateral lung candidates should the accepting center back out, allowing the OPO to place the organ where it is most needed.

•The Committee also recommends an option for OPOs to indicate elevation data as it could be helpful for lung programs to know altitude information.

Overall, the Committee supports the proposal and requests that the above comments be taken into consideration.

Region 10 | 03/19/2024

7 strongly support, 12 support, 2 neutral/abstain, 0 oppose, 0 strongly oppose

This was not discussed during the meeting, but attendees were able to submit comments with their sentiment. One attendee stated that there is a need to improve pediatric access to lung donors. Another attendee noted that offer filters should be implemented in order to decrease late offer declines that lead to non-transplantable organs. It was also noted that the addition of offer filters for lung transplant programs will assist in decreasing allocation time, so long as programs effectively utilize offer filters. It was suggested, that when implemented, it should be an opt out option based on previous acceptance behavior for the transplant programs.

Region 9 | 03/19/2024

1 strongly support, 6 support, 3 neutral/abstain, 0 oppose, 0 strongly oppose

OPTN Organ Procurement Organization Committee | 03/19/2024

The OPTN Organ Procurement Organization (OPO) Committee thanks the OPTN Lung Transplantation Committee for their efforts on the Promote Efficiency of Lung Allocation proposal.

The Committee expressed great support for the “bypass bilateral and other lung” button concept, noting that the current manual process is overly time-consuming. The Committee shared that a current challenge that OPOs face is that once single lungs are offered, and then declined, they must go back on the match run to identify which programs wanted bilateral lungs. The Committee recommended that OPTN Policy allow programs to continue moving forward with allocation in the case of late decline of single-laterality lungs, instead of requiring OPOs to re-notify programs.

The Committee does not expect new additional data fields to be burdensome, as OPOs are already capturing this information. The Committee recommends providing educational materials with the implementation of new data fields, to ensure consistency and understanding.

OPTN Transplant Coordinators Committee | 03/19/2024

The OPTN Transplant Coordinators Committee appreciates the opportunity to comment on the Promote Efficiency of Lung Allocation proposal. The Committee offers the following as feedback for consideration.

The Committee appreciates the “opt-in” concept for geographically isolated areas such as Alaska, Hawaii, and Puerto Rico. However, the Committee acknowledges that aggressive transplant programs hesitant to miss potential offers may need convincing regarding the benefits of offer filters.

The Committee discussed several suggestions to encourage the adoption of lung offer filters:

· Sharing historical data on the ratio of offers accepted to total call volumes received, highlighting the potential reduction in coordinator burden.

· Emphasizing that filtering lower quality or geographically distant offers would allow transplant staff to focus on offers that align with program criteria and have a higher likelihood of acceptance, reducing coordinator and administrator burden.

· Leveraging experience and best practices from the implementation of Kidney Offer Filters, connecting centers to share insights.

· Clarifying terminology to distinguish offer filters from medical acceptance criteria, eliminating potential confusion.

Additionally, the Committee supports the inclusion of a bypass button to increase efficiency in the offer management process.

Region 6 | 03/19/2024

2 strongly support, 8 support, 3 neutral/abstain, 0 oppose, 0 strongly oppose

This proposal was not discussed during the meeting, but attendees were able to submit comments. One attendee commented that they supported giving programs the option to opt-in for offers from geographically isolated areas (Hawaii, Alaska, Puerto Rico). They went on to comment that they supported allowing OPOs allocating a single lung, the option to bypass candidates who need a double lung transplant. 

HonorBridge | 03/19/2024

Allocation efficiency is of great importance to HonorBridge. Proximity of recipient to donor hospital remains important to minimize transportation challenges and stretching of the limited resources of aircraft availability, pilot time, and transplant center procurement staff. Additionally, it has been our experience that increasing distances between donor hospital and recipient center can lead to increased case times which can be difficult to manage with donor family expectations and desires to bring their loved one’s donation to a timely closure. A complex donor in combination with extended transportation time can impact acceptance rates, outcomes, and utilization.

We encourage the utilization of filters and the enhancement to bypass bilateral and other lung when only single lung is available, as they should aid in allocation efficiency.

We concur with other OPO feedback that the inclusion of donor information related to nut allergies and prior sternotomy is easily achieved as it is currently collected in the DRAI.

UW Health Organ and Tissue Donation | 03/18/2024

This policy proposes the use of ‘filters’ for lung centers to align with their acceptance practices and would help OPOs allocate suitable lungs to centers that will take them. For instance, if a center has a rule out for P/F ratio or infection, centers who would not accept these can utilize filters and speed up lung allocation. As an OPO we find that lung allocation is time-consuming given the unique needs and requests of lung centers (vent settings, ABG, antibiotics, imaging, etc). We would support a policy to speed up lung allocation and get organs to the transplant centers most likely to use them.

OPTN Kidney Transplantation Committee | 03/18/2024

The Kidney Committee (the Committee) thanks the OPTN Lung Transplantation for their efforts on the Promote Efficiency of Lung Allocation proposal. The Committee supports this proposal and provided the following feedback for consideration.

The Committee recommended that offer filters include the capability for programs to build multi-factorial filters for specific geographically isolated areas; for example, programs could implement a filter for DCD donors from Alaska. One member noted that this would allow programs to maximize efficiency gains from screening, allowing them to filter certain offers while still receiving other offers from these areas. Another member noted that advanced filtering for organs from geographically isolated areas could benefit OPOs attempting to allocate these organs, allowing them to send offers to programs that will accept the organs sooner. The member explained that there may be specific programs and surgeons that may be willing to accept organs from much further away. 

Region 7 | 03/18/2024

4 strongly support, 8 support, 5 neutral/abstain, 0 oppose, 0 strongly oppose 

This was not discussed during the meeting, but attendees were able to submit comments with their sentiment. One attendee noted their support of the proposal stating that this will be a great tool for lung programs and will increase efficiency. Another attendee suggested that the data should be analyzed at a later point to confirm that the requirements are not too onerous. Another attendee added that the proposal does not go far enough and there needs to be more data fields and the ability to combine filter parameters for individual candidates, not just program specific filters. Lastly, another attendee noted that lung allocation can be a time-consuming process given the unique clinical needs of lung donors such as ventilator settings, ABGs, and imaging; applying offer filters will help with lung allocation efficiency.

OPTN Pancreas Transplantation Committee | 03/18/2024

The OPTN Pancreas Transplantation Committee thanks the OPTN Lung Transplantation Committee for their work on the proposal and the opportunity to provide feedback.

The Committee is in support of this proposal and provided some feedback for consideration:

• The Committee cautions that programs in rural or remote areas often see viable organ opportunities leaving their state or local area and recommends that an “opt-in” option be provided, similar to the “opt-out” for geographically isolated areas such as Alaska, Hawaii, and Puerto Rico.
• The Committee recommends requiring periodic review and renewal of filter settings by transplant programs, such as an annual or biennial renewal process. The Committee recognizes that transplant program practices and personnel can evolve over time, so enforcing regular review would ensure filter accuracy and prevent overly restrictive filters from being applied indefinitely based on outdated program preferences or behavior patterns.
• Additionally, the Committee endorses exploring mechanisms to create candidate-specific exceptions to program-level filters when warranted by an individual's unique clinical situation. While standardized filters promote efficiency, the ability to bypass filters for exceptions could prevent unintentionally screening out viable organ opportunities for candidates who may need to cast a wider net.

The Committee was in overall agreement that this proposal is a good move forward to address efficiency.

OPTN Liver & Intestinal Organ Transplantation Committee | 03/18/2024

The OPTN Liver & Intestinal Organ Transplantation Committee thanks the OPTN Lung Transplantation Committee for their efforts on the Promote Efficiency of Lung Allocation proposal. The Committee supports system enhancements that help reduce unwanted organ offers.

The Committee agrees that data collection on deceased donors related to anaphylaxis to peanut and/or treenut would be beneficial in the context of liver transplantation. The Committee recommends that the data element be expanded to collect information more generally on anaphylaxis as this also can occur for other common allergies such as fish or eggs.

The Committee also supports the ability for transplant programs to opt-in to receiving offers from geographically isolated areas for liver allocation purposes. They note that it would be helpful to indicate whether they are willing to accept offers from geographically isolated areas rather than relying on nautical miles to capture these areas.

Region 1 | 03/18/2024

2 strongly support, 7 support, 4 neutral/abstain, 0 oppose, 0 strongly oppose

American Society of Transplant Surgeons | 03/18/2024

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Region 5 | 03/15/2024

5 strongly support, 25 support, 7 neutral/abstain, 0 oppose, 0 strongly oppose 

Region 5 supports this proposal and an attendee suggested there should be more attention given to allocation for pediatric candidates.  

American Society of Transplantation | 03/15/2024

The American Society of Transplantation (AST) generally supports the proposal, “Promote Efficiency of Lung Allocation,” and offers the following comments for consideration:

• The AST supports providing additional tools to transplant programs to make efficient and customized decisions. We recommend continuing to collect data to determine the holistic impact and to further optimize these systems.
• The AST supports the proposed new data fields that will provide a greater opportunity to increase allocation efficiency and minimize lung offers that a program would only accept in very specific circumstances. Lung programs have seen an exponential increase in offers since the OPTN implemented continuous distribution for lung allocation. This has decreased efficiency in allocation as well as inundated centers with an increased number of offers they would not accept based on donor characteristics.
• Most of the proposed filter data is currently collected by OPOs which should help minimize any data collection burden upon implementation. As for additional possible fields that could be helpful:
• Predicted total lung capacity (pTLC): Programs often screen donors based on pTLC, but manual calculations are error-prone and may impact acceptance or organ placement. The AST suggests that pTLC be pre-calculated in UNet using information already available for both donors and candidates, including age, height, and gender. This will increase efficiency and allow transplant programs to apply pTLC screening criteria at the time of candidate registration.
• CMV serology and EBV serology: the addition for CMV and EBV serologies results (+/-) to enhance patient safety at time of organ offer and to minimize the need for manual screening.
• Additional donor information and other filter adjustments will likely be needed as filters are introduced and the community becomes familiar with their usage.
• The addition of a button to bypass candidates who would not accept an offer if only a single lung is available is appropriate. The AST also supports a system enhancement that would require transplant programs to opt in for offers from geographically isolated areas. This would create an increased layer of efficiency for those programs that have no intention of accepting organs from Alaska, Hawaii, or Puerto Rico due to their relative geographic separation.

Association of Organ Procurement Organizations | 03/14/2024

Regarding the OPTN proposed changes to Promote Efficiency of Lung Allocation, AOPO supports these changes, which can potentially improve the lung allocation process. Requiring OPOs to enter “History of anaphylaxis to peanut and/or tree nut” and “Previous sternotomies” into the system will have minimal impact on OPOs. On the transplant side, these changes will have little or no impact as the filters are optional. Including exclusion filters for these questions will appropriately eliminate offers to programs that utilize filters and will not accept these organs. If a program does not set lung filters, it can still use this information to streamline its decision-making process. 

Luke Preczewski | 03/12/2024

This is headed the right direction and I applaud the committee for that. Would add pTLC to the criteria - the data are already available to do this so it results in no increased burden, just a calculation in the system.

I am an employee of an OPTN member, but my comments are submitted on behalf of myself as a transplant professional, not on behalf of my employer nor any other organization.

Region 3 | 03/11/2024

3 strongly support, 6 support, 7 neutral/abstain, 0 oppose, 0 strongly oppose

American Society for Histocompatibility and Immunogenetics (ASHI) | 03/09/2024

This proposal is not pertinent to ASHI or its members.

OPTN Operations and Safety Committee | 03/07/2024

The Operations and Safety Committee thanks the OPTN Lung Transplantation for their efforts on the Promote Efficiency of Lung Allocation proposal. The Committee is in support of the proposal and provided the following questions and feedback for consideration.

The Committee suggests educational offerings for members and add that this would be beneficial in increasing adoption of the offer filters tool. The Committee noted their previous work on kidney offer filters showing an increase in the adoption of offer filters by providing various educational offerings.

In response to the proposed member actions for OPOs to report additional data on donors regarding anaphylaxis to peanut and/or tree nut, there was agreement in collecting anaphylaxis, as current documentation only questions allergies, which would not capture anaphylaxis. The Committee voiced preference in collecting a discrete data field, however, there were suggestions in how this information could potentially be collected in the DRAI to help reduce the burden of adding additional questions to collect information on.

The Committee suggested consideration for taking the history of anaphylaxis through the standardized Donor Risk Assessment Interview (DRAI) approval process. This would be an addendum that would need to be added into the donor’s medical records to be able to collect on a standard basis. If this were added to the DRAI, it would be more consistent standard reporting for OPOs. Additionally, the Committee suggests merging this proposed field into the OPTN Donor Data and Matching System to reduce the burden of asking an additional question. Although there is a surgical question in the DRAI, it would be helpful if this information was included in the Mini-Medical/Social. The Committee reasoned that the DRAI is similar across programs and that if there were a way to connect this record into the system, this would be helpful. The Committee agreed with the use of a bypass button as it would be useful rather than sending offers that would require a response when it is clear an offer does not meet a program’s needs. The Committee acknowledges that as the lung offer filters tool advances, there is opportunity to build upon this tool to increase efficiency through the match run.

Region 8 | 03/05/2024

3 strongly support, 11 support, 3 neutral/abstain, 0 oppose, 0 strongly oppose

A member pointed out that filters worked well for kidney but will need data follow-up to determine if there are unintended consequences. An institution questioned the cost/benefit of adding the "history of anaphylaxis to peanut and/or tree nut" field since it is a rare event and has the potential to be marked positive in circumstances where risk of donor transmission of anaphylaxis would be low. They also questioned whether the surgeons want to know about previous thoracotomies, as well as sternotomies. They suggested expanding the set of potential criteria available to transplant programs. 

LifeCenter Northwest | 03/01/2024

This proposal makes sense for several reasons:

1. Promoting Utilization of Organs: By allowing transplant programs to receive offers from geographically isolated areas like Hawaii, Puerto Rico, and Alaska, the proposal aims to promote the utilization of organs from these regions. It allows programs to be focused in their receiving offers, but not open them up to a consecutive circle that includes half of the United States.
2. Efficiency: The proposal seeks to improve the efficiency of organ allocation by ensuring that organs from geographically isolated areas are not overlooked simply because they fall outside the typical recovery distance specified by transplant programs. This helps ensure that organs are allocated based on clinical need rather than geographic proximity.
3. Managing Organ Offer Volume: By allowing transplant programs to selectively receive offers from specific regions, the proposal helps programs manage their organ offer volume more effectively. This is particularly important for lung transplant programs, which may receive a high volume of offers and need mechanisms to streamline the process without overwhelming staff or resources. 

Region 2 | 02/29/2024

6 strongly support, 13 support, 5 neutral/abstain, 0 oppose, 0 strongly oppose

This was not discussed during the meeting, but attendees were able to submit comments with their sentiment. One attendee expressed support for increasing efficiency of lung allocation as long as the committee monitors transplant outcomes. Another attendee noted that moving forward it is important to consider policies on DCD guidelines for how decisions can be made about use of organs without NRP when programs do not agree on the need for NRP. Lastly, another attendee is encouraged by the potential benefit to the community with this proposal. They urge early transparency before implementation in how a center's use of offer filters will impact reported and publicly available donor acceptance rates, in terms of MPSC quality review. Additionally, they suggested the consideration of inclusion of broader filter availability, such as potentially significant years of smoking history and DCD brainstem reflexes being maintained.

OPTN Heart Transplantation Committee | 02/29/2024

The OPTN Heart Transplantation Committee (Committee) thanks the OPTN Lung Transplantation Committee for requesting feedback about the Promote Efficiency of Lung Allocation proposal during the Committee’s February 7, 2024 meeting. The Committee members appreciated the questions addressing potential future improvements to the organ offer filter for hearts functionality currently in development. There was consensus that heart transplant programs would benefit from the opt-in functionality because it would allow programs to expand their potential donor pools to include more remote areas without receiving excessive offers. For some programs, the expanded travel distances could allow them to take advantage of recent improvements involving perfusion technology to utilize donor organs they maybe would not have considered previously. The Committee members encouraged the Lung Committee to review the results of the opt-in function to determine if the change actually results in more donor organs traveling from remote/isolated areas and fewer such donor organs traveling to remote/isolated areas. 

Region 11 | 02/29/2024

6 strongly support, 4 support, 8 neutral/abstain, 0 oppose, 0 strongly oppose 

Jarrod Newlin | 02/28/2024

I support the proposed enhancements -

Current lung filter lacks available data points to make an efficient filter.

Would support more data points within the lung filter such as pack years for smoking history, previous sternotomy, donor COVID-19+ testing, COPD diagnosis, Pa02 challenge resulted parameters. Also support as stated above adding pTLC & lung compliance data points within the donor summary.

Region 4 | 02/26/2024

2 strongly support, 8 support, 4 neutral/abstain, 0 oppose, 0 strongly oppose 

This proposal was not discussed during the meeting, but attendees were able to submit comments. One attendee commented that they appreciated the committee’s work to promote efficiency and agreed that it should be a primary concern.

Robert Reed | 02/13/2024

Much of the offer filter capabilities seem redundant with limits we can already put in place and I don't see why we would use the filter feature other than for informational purposes.

I would, however, find a lot of added value with the ability to add limits based on pTLC and I think that would also make allocation more efficient as there should be far fewer refusals based on sizing if this capability were added. It would be important to be able to specify the prediction equation (GLI versus Hankinson primarily) for generation of pTLC, and to be able to customize the filter according to diagnosis codes (maybe even individual transplant candidate). It would also be necessary to be able to add a layer to the filter to be able to specify parameters for a single lung that differ from the parameters for a double lung.

Déboralis Ramos | 01/31/2024

Strongly Support

Neeraj Sinha | 01/26/2024

I support the proposed enhancements.

Following are other potential enhancements to consider:

1) Predicted total lung capacity pTLC criteria: Many programs screen donors based on pTLC. Donor desk coordinators need to calculate the donor pTLC at the time of offer, and program coordinators need to provide a list of calculated pTLC for candidates to the donor desk so that appropriate matching can be done by on-call MDs. There is a potential for error when this process is done manually. Also calculation takes precious time away while operating under a constrained timeline. pTLC can be pre-calculated by the Unet matching system using information already available for both donors and candidates on unet - age, height and gender; and not only can the pre-calculated information be available at the time of match offer, but programs can also apply screening criteria based on pTLC at the time of candidate registration on Unet (just like we currently do for height and age.) This has a potential to improve allocation efficiency.

2) CMV serology and EBV serology: Just like there are opt-in or opt-out boxes for hepatitis B and C serology/NAT, can we also have opt-out boxes for CMV serology and EBV serology? In conjunction with other factors, a program might not want to accept a CMV positive or EBV positive donor for a CMV negative or an EBV negative candidate respectively. In general CMV mismatch patients add to complexity of care in post-transplant phase and have increased morbidity due to risk of CMV disease and risk of rejection in the setting of CMV related immune stimulation. CMV/EBV mismatch also needs to be avoided in a candidate with CKD where belatacept strategy is being anticipated prior to transplant. With opt-out boxes, time-demanding need to manually screen for mismatches would be eliminated.

3) High resolution HLA typing: Currently OPOs provide low resolution HLA typing. And many a positive virtual cross match based on low resolution HLA typing turn out to be negative in retrospect when virtual is re-performed after high resolution results are available. In my experience, about 50 % of low resolution typing based virtual turn out to be negative when re-perfomed against high resolution typing. High resolution typing is more expensive and has a turn around time (TAT) ranging from 4 - 12 days depending on laboratory performing it. OPOs could initiate the practice of sending for a high resolution typing on all donors at the outset to a fast TAT lab. The increase in number of transplants would likely justify the increased expense. This perhaps needs a separate OPTN project.

4) Lung compliance information (peak/plateau P while on Volume mode and TV while on pressure mode) is often lacking when offer comes. Transplant MDs and donor desk coordinators have to get this information by asking follow up questions. This information should be available on Unet (with fields added to unet to add this information) to increase allocation efficiency.

5) Uploading or availability of CxR image should be a must at the time of offer. Mere uploading of CxR report as per current minimum requirement would not suffice. Of note, most programs now routinely expect CT chest to be done, and if not done within preceding 48 h, would ask for CT chest. Also of note, it is exceedingly rare to accept a donor without bronchoscopy. In the context of such expectations, when an offer comes to the program without available CxR image and only with a report, that can be a bit exasperating.

Anonymous | 01/24/2024

Do not allocate until the person allocating knows brain stem reflexes if dcd. Recent X-ray. Current donor management known. Important for person that knows the donor to be instantly avail to talk not an offsite non clinical person reading off a piece of paper.