Multi-organ transplantation
What is multi-organ transplantation?
Some patients have not only one but multiple organs that have failed or are likely to fail. They are thus in need of a transplant of multiple organs. Transplant programs must carefully weigh whether to accept a patient for a multi-organ transplant or a single-organ transplant, because patients sometimes recover function in other organs after receiving a single-organ transplant.
In most cases of multi-organ transplantation, the organs are transplanted from the same donor (simultaneous transplantation). Receiving organs from the same donor instead of from different donors may reduce the level of the patient’s immune system response and lower the risk that their body will reject the organs.
In other cases, a patient may have two failing organs, but only one is transplanted. This may be done when a treatment team determines that one donor organ could restore function to the other failing organ. If the second organ does not regain function, the patient may get special priority for a transplant of that organ through a safety net multi-organ policy. Under a safety net, the transplant recipient can qualify for additional priority for the non-transplanted organ if it continues not to function. One such policy was approved by the OPTN Board of Directors in June 2022; you can read about it here.
Given the scarcity of organs, allocating more than one organ to a single patient must be weighed against the opportunity to allocate lifesaving organs to multiple patients. In an effort to create a more equitable system for all patients, the OPTN has established a new committee to build upon existing multi-organ allocation policies.
About this committee
The Ad Hoc Multi-Organ Transplantation (MOT) Committee was established in 2021. It is charged with developing and proposing allocation policies that address multiple organ groups and the practice of multi-organ allocation. The committee is part of the Organ Procurement and Transplantation Network’s (OPTN) key initiative to improve equity in transplant opportunities and its strategic plan (PDF) goal to provide equity in access to transplants.
Evolution of multi-organ transplantation policy
The two organ combinations transplanted most frequently are kidney-pancreas and heart-lung. Accordingly, the OPTN adopted policies early in its operation to address these specific organ combinations.
In the 1990s, the OPTN developed policies to address other organ combinations, particularly those including the heart, liver, or lung. Those policies have continued to be modified over time.
OPTN multi-organ policies generally require organ procurement organizations (OPOs) to allocate multiple organs from the same donor to patients who meet certain criteria. The OPTN has continued to update these policies to reflect changes in single-organ allocation policies, including actions that removed donation service area (DSA) and regions from organ allocation.
- In 2010, the OPTN updated kidney and pancreas allocation policies regarding simultaneous kidney-pancreas allocation.
- In 2017, the OPTN implemented policies for liver-kidney allocation in response to concerns that for some recipients, kidney function may recover after they receive a liver-alone transplant. The policies are intended to identify the candidates who may benefit the most from a combined transplant, while providing extra priority for liver recipients who do not regain kidney function.
- The policies established eligibility criteria for simultaneous liver-kidney allocation and a safety net for liver-alone transplant recipients who also need a kidney transplant.
- Eligibility criteria are the qualifying conditions for an OPO to offer a candidate a second organ simultaneously with another organ. The criteria include clinical reasoning to justify giving multiple organs to one person.
- The safety net gives some priority to candidates who receive a liver but meet medical criteria to qualify for a kidney shortly after transplant. In this way, the safety net can “catch” patients who do not qualify to receive multiple organs at the same time, but still require a second organ transplant.
- In 2019, the OPTN Ethics Committee released a white paper, Ethical Implications of Multi-Organ Transplants (PDF), which outlined a number of recommendations for continued policy development on multi-organ allocation.
- In 2022, the OPTN implemented changes to general multi-organ policy to clarify when OPOs are required to allocate multiple organs to one candidate. The MOT Committee also released a proposal for public comment to establish eligibility criteria and safety net policies for heart-kidney and lung-kidney allocation.
Progress
The timeline for the MOT Committee’s work aligns with the transition of organ allocation to a continuous distribution framework.
| Timeline | Action |
|---|---|
| April 2021 | Ad Hoc Multi-Organ Transplantation Committee established |
| December 2021 | Continuous distribution of lungs approved |
| January 2022 Public Comment | Eligibility criteria and safety net for heart-kidney and lung-kidney |
| January 2023 Public Comment | |
| August 2023 Public Comment | Prioritizing kidney multi-organ vs. single organ candidates in continuous distribution |
| January 2024 Public Comment | Eligibility criteria and safety net for heart-liver and lung-liver |
| August 2024 Public Comment |
Update heart-lung policy Multi-organ considerations for continuous distribution of heart and VCA |
Committee proposals
The MOT Committee’s first proposal on heart-kidney and lung-kidney allocation was open for public comment from January 27 to March 23, 2022 and approved by the Board of Directors in June 2022.
The MOT Committee has a concept paper on kidney multi-organ allocation and a proposal on liver-kidney allocation out for public comment from January 19 to March 15, 2023.