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Ethical implications of multi organ transplants

Proposal Overview

Status: Public Comment

Sponsoring Committee: Ethics Committee

Strategic Goal 2: Provide equity in access to transplants

Read the proposal and white paper (PDF; 1/2019)

Contact: Abigail Fox


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Executive summary

The allocation policies for multi-organ transplant (MOT) have the potential to create inequity in the organ distribution process, either in the rate of transplantation or in the time to transplantation. Such potential inconsistencies may affect the patients who are awaiting MOT as well as those who are awaiting single organ transplantation (SOT) because both groups depend upon available organs from the same limited donor pool. Prioritization of MOT candidates and the allocation rules for each combination have not been standardized across the different organs. As a result, the current allocation system has generated confusion in the transplant community about the rationale for differences in MOT allocation plans between different organ combinations.

The OPTN/UNOS Ethics Committee (hereafter “The Committee”) performed an analysis of policy and relevant literature focusing on the potential conflict in the principles of equity and utility in the allocation of multi-organ transplants. Ultimately the Committee affirmed that MOT should reflect a balance between equity and utility, with the understanding that no system can maximize both. Because the ethical issues of equity and utility that MOT raises are common with all organ combinations, the ethical principles must be carefully considered and weighed in the development and modification of MOT policy. This white paper details the ethical dilemmas that arise from conflicts between equity and utility and the recommendations of the Committee regarding the allocation of multi-organ transplants.

The 2018 OPTN/UNOS Strategic Plan called for the OPTN to “measure equity in allocation, including geographic disparities and multi-organ disparities.” This white paper lays the foundation for other committees to clarify or modify existing multi-organ allocation policy and to do so in a consistent, principled manner, which aligns with the OPTN strategic goal to provide equity in access to transplant.

Comments

Xingxing Cheng | 02/07/2019

This is a comprehensive, lucid and thoughtful summary of the pertinent ethical issues in multi-organ transplantation. As a practising transplant nephrologist, I thank the 2018 UNOS Strategic plan for making measuring equity in multi-organ allocation a priority, and the UNOS Ethics Committee for this important work. I have two comments for future editions: 1) The "Treatment options other than transplantation" section should discuss dialysis more as a viable treatment option. SOT (non-kidney) + dialysis SHOULD be openly discussed as an alternative to MOT. For most patients with kidney failure who do not have another organ failure, dialysis is most times the firstline and frequently the only treatment option for their kidney failure. It appears to violate the equity principle if a patient who with another organ failure is treated differently, such that a life-saving organ transplant + dialysis is not an option. This discussion will also lend itself well to the section on "Degree of Need" and "Standardize criteria for MOT". 2) I frequently see cases resulting from the fact that KT is always the secondary organ. When a KT candidate has a mild-moderate degree of other organ failure (most often heart or liver), which is not severe enough to place them within reach of a heart or liver transplant, the patient cannot receive a KT (and receive quantity and quality of life benefits from it) regardless their wait-time. The equity principles at conflict here are interesting to explore and opens the question of, when the kidney disease burden is greater than that of other disease burden, whether some additional priority point system (for instance, those granted to patients with primary hyperoxaluria awaiting liver-kidney) can be adopted to "level the playing field".

Region 7 | 02/08/2019

Region 7 vote-5 strongly support, 9 support, 1 abstention There was a question asked about whether or not SLK was considered when developing this paper. The committee needs to make sure that there is no conflict with current policy. There was also concern that the paper did not include K/P which is a common transplant. There was a recommendation that all multi-organ transplants be considered. Some members commented that removing DSA as a unit of allocation could disadvantage recipients of MOT. Another recommendation to the committee was to consider the effect of any policy on vulnerable populations and carefully monitor the impact post implementation.

OPTN/UNOS Thoracic Committee | 02/15/2019

The OPTN/UNOS Thoracic Organ Transplantation Committee commends the Ethics Committee for their work on analyzing the ethical principles involved when considering MOT policy and felt the white paper provided a reasonable foundation to inform future multi-organ allocation policy development. One member opined that removal of DSA from organ allocation policy may disadvantage multi-organ candidates, and that geography should be an important consideration when developing multi-organ policy, as well as something to be cognizant about in the current discussions and changes to organ distribution. Otherwise, the Committee was supportive of the white paper’s recommendations.

Paul Grimm | 02/16/2019

Situation. 11-year-old child on dialysis, highly sensitized, without a living donor and with 2 years of wait time and undergoing desensitization. PRA 92%. Excellent KDPI donor kidney is allocated to a high PRA 70-year-old individual. The other kidney is allocated to an older adult with pancreas. Our pediatric patient was the backup for both kidneys. If it was solitary kidney donor, the child would have been allocated the kidney that went to the K/P. Because it was a pancreas/kidney, the kidney was taken from the child. Is this fair? The child is ultimately going to live a lot longer than the 70-year-old and the K/P recipient. The child was highly sensitized and had been waiting a long time with no suitable offers, it would likely be a very long time before another kidney of the same quality would be available. This is not an outlying nor rare event. This is commonly seen time and again in our region. As the pancreas transplant is not lifesaving but is life-affirming, as is the kidney transplant, why should the pancreas demand priority? What is the rationale for the kidney being dragged by the pancreas and not vice versa? Suggestion: This issue could be fixed by making kidney criteria be primary. If a person needs a pancreas as well, that would be dragged if they got allocated the kidney. Then the competition for everybody needing a kidney would be leveled for at least this organ combination. Another option would be to alternate allocations in this situation so the kids have some shot at high quality donors. i.e. kidney goes to K/P this time, then the next time it goes to a child.... Either of these options would go very far to reduce the inequities of allocation for which children inordinately suffer, especially in regions with active K/P programs.

Region 1 | 02/18/2019

Region 1 vote-7 strongly support, 4 support, 0 abstention, 0 oppose, 0 strongly oppose