Comments

HonorBridge | 03/19/2025

HonorBridge thanks the committee for their work in providing plans for MOT.
The tables provide some needed guidance but utility would be easier if there were built in automation or visualization to know where you are in the complex process. Also policy does not address how the tables would be impacted if there is a late turn down when an OPO might be further down the allocation plan.

OPTN Pediatric Transplantation Committee | 03/19/2025

The OPTN Pediatric Transplantation Committee (Pediatric Committee) commends the OPTN Multi-Organ Transplantation (MOT) Committee for its ongoing commitment to this complex work. The request for feedback is a crucial step toward streamlining allocation and establishing fair, consistent multi-organ sharing practices. However, the Pediatric Committee recommends further refinements to better support pediatric transplant access, particularly for pediatric kidney-alone and liver-kidney candidates.

Placement of pediatric kidney candidates in pediatric donor tables

The Pediatric Committee strongly advocates for pediatric kidney-alone candidates to be sequenced before pancreas and kidney/pancreas (K/P) classifications in the proposed allocation orders for DBD donors aged 11-17 with KDPI 0-34% and DBD donors aged <11 with KDPI 35-85%.

There are significant concerns that prioritizing pancreas and K/P candidates will further limit the donor pool for pediatric candidates. The Pediatric Committee emphasizes that pediatric kidney-alone candidates often have limited access to appropriate organs, given that pediatric candidates typically are not offered kidneys with a KDPI >35%. Some members felt prioritizing K/P candidates over pediatric kidney-alone candidates represents risk for missed transplant opportunities for pediatric patients, particularly given the frequency of late declines among K/P recipients. These declines can result in pediatric-appropriate kidneys being allocated to lower-priority candidates instead of pediatric kidney recipients in need.

Regarding the allocation table for DBD donors aged <11 with KDPI 35-85%, the Pediatric Committee supports the inclusion of pediatric candidates in Classification 13 and 14. The Committee maintains that pediatric kidney candidates should be prioritized for pediatric donor organs over K/P candidates.

Additionally, the Pediatric Committee highlights the need to factor medical urgency and sensitization needs into kidney classifications for pediatric candidates. Highly sensitized pediatric candidates have much lower access to transplant opportunities. Due to their increased sensitization and decreased donor compatibility, these candidates may face significantly prolonged wait times.

Finally, the Pediatric Committee supports the placement of pediatric candidates in the allocation table for DBD donors aged <11 with KDPI 0-34%. This will benefit children who can only receive a smaller kidney due to small stature, vascular access issues, or other medical factors.

Considerations for pediatric liver-kidney candidates

The Pediatric Committee expresses concerns regarding pediatric liver-kidney access within the proposed allocation framework. Pediatric liver-kidney candidates may have reduced access to transplant if implemented as currently proposed, since the kidney would not be automatically allocated with the liver. Committee members noted, though small in numbers, liver-kidney is the primary type of pediatric multi-organ transplant. A thorough review of pediatric liver-kidney candidate characteristics is recommended to better understand the impact to this group.

Considerations for pediatric heart-liver candidates

The Pediatric Committee asks that heart-liver candidates, particularly those with Fontan-associated liver disease, be considered among other priorities. Fontan patients often develop significant complications, including cancer, making their liver needs medically urgent. The Committee encourages further evaluation of how heart-liver candidates are prioritized to ensure equitable access for pediatric patients requiring this type of transplant.

Infinite Legacy | 03/19/2025

Infinite Legacy is pleased to provide the following comments and recommendations for this policy. Standardizing multi-organ allocation with priority would bring efficiency to the allocation process by determining the priority of which multi-organ cases should be allocated. Currently, each match only lists organs needed, so the development of the OPTN match run system needs to clearly identify these priorities and make additional information readily available. Under the current process, single organ offers must be made as backup to multi-organ offers after acceptance to mitigate out-of-sequence offers due to late or intra-op declines. Greater attention to criteria to list recipients for multi-organ transplants should also be considered by the committee to promote efficiency by not allocating an organ to a multi-organ recipient when it is ultimately declined for one of the organs.
Multi-organ offers could be made from all match runs if there were changes to the current OPTN IT platform to include an interactive match. This would be complex but would add efficiency to the allocation process. Otherwise, we support running all possible match runs, with a review of which organs have multi-organ needs, prior to making primary offers. In such cases, the individual matches would need to indicate allocation priority. We support the kidney priority as it was developed from a survey of the OPTN community based on a Likert scale of priority and a review of the data. Adding the 11-17 pediatric patients under the high PRA KP priority will address applicable pediatric concerns.

International Society for Heart and Lung Transplantation | 03/19/2025

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Mid-America Transplant | 03/19/2025

MT generally supports updating the Multi-Organ Allocation Policy to enhance equity and utility. However, we believe this specific policy is too complex to be implemented consistently, as it requires OPO staff to manually navigate intricate rules under time constraints. MT recommends that OPTN leverage modern technology to automate the implementation of complex policies like this within the national allocation system, reducing human error and improving efficiency in the transplantation process.

Region 10 | 03/19/2025

There was discussion about pediatric kidney candidates and whether they should be prioritized above multi-organ allocation tables. A suggestion was made to reserve one kidney from a donor for a multi-organ candidate while ensuring the other is allocated to a pediatric patient. However, it was noted that the committee avoided making changes to current allocation policies and did not address medical urgency within single-organ classifications when a candidate needs more than one organ. Alignment of pancreas and kidney allocation for 100% CPRA values was discussed, but since 100% CPRA is not currently a classification within pancreas allocation, it was not included in this request for feedback. There was also a recommendation to improve screening criteria for multi-organ placement to create a more dynamic system that accounts for real-time information. Overall, there was support for the committee’s direction, with acknowledgment that continuous distribution (CD) for pancreas may address concerns for highly sensitized candidates. However, concerns remain that pediatric kidney candidates will continue to be underrepresented, and modifications to allocation policy should be considered. While there was strong support for prioritizing high CPRA candidates, concerns were raised about pediatric patients being bypassed for kidneys that instead go to multi-organ transplant recipients. This was seen as increasing risks for pediatric patients by prolonging wait times and delaying transplants. A suggestion was made to prioritize pediatric kidney candidates in specific cases by modifying allocation policies for donors aged 18-69 with KDPI 0-34%, moving kidney alone pediatric candidates above . kidney/pancreas candidates. A further category could be created for brain dead donors aged 18-69 with KDPI 0-19%, prioritizing pediatric kidney candidates in a similar manner. It was suggested that modeling be conducted to evaluate the potential impact of these options and that input from the Pediatric Committee be incorporated into future policy modifications.

OPTN Pancreas Transplantation Committee | 03/19/2025

The OPTN Pancreas Transplantation Committee appreciates the opportunity to comment on this request for feedback and recognizes the great work that has gone into drafting these allocation tables. The Committee submits the following feedback for consideration:

Members expressed concerns about the classification shift for donors aged 11-17 with a KDPI of 0-34%, which prioritizes Kidney Class 6 candidates over Classification 4 pancreas candidates. Given that this donor category represents nearly 50% of pancreas donors, members stressed the potential negative impact on pancreas allocation.

Concerns were voiced regarding the lack of differentiation between medically urgent and routine KP candidates, with members emphasizing the need for clear prioritization criteria once medical urgency for pancreas is incorporated into continuous distribution.

It was highlighted that in multi-organ allocation (e.g., liver-kidney, heart-kidney), the primary organ is lifesaving, while the kidney provides only an incremental survival benefit. The Committee stresses the importance of distinguishing between receiving the primary organ alone versus both organs together.

Additional concerns were raised regarding CPRA 100 candidates in kidney-pancreas allocation, noting that a KP candidate with CPRA 100 is significantly disadvantaged compared to a kidney-alone candidate with the same sensitization. Since pancreas allocation does not prioritize CPRA 100, highly sensitized KP candidates rank much lower despite the expectation that they would be treated similarly to kidney-alone candidates. While this may affect a small number of patients, members emphasized that it presents an unfair disadvantage. The Committee recommends addressing this disparity by ensuring that if a 100% CPRA candidate is listed for KP, the kidney would "pull" the pancreas rather than the other way around. Members highlighted this potential change could ensure fair allocation for highly sensitized KP candidates.

University of California San Diego Medical Center | 03/19/2025

Encourage the committees to reconsider the CAS to be lower for allocation. Keeping the heart allocation the same as current practice/policy does not address the challenges for lung transplant candidates. Heart transplant waitlist mortality is half to a third of the lung transplant waitlist mortality. Heart status I and II are on additional devices that are not readily available for lung transplant candidates. The NRP and DCD benefit heart, liver, and kidney transplant candidates but not the lung candidates in the same manner.

American Society of Transplant Surgeons | 03/19/2025

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The Society of Thoracic Surgeons | 03/19/2025

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Region 6 | 03/19/2025

Concerns were raised about the complexity of multi-organ allocation from an OPO perspective, particularly the inability to allocate multiple organs simultaneously, which would increase challenges and donor case times. The proposed approach may require OPOs to switch between multiple match runs, making allocation more complex and increasing the likelihood of errors or out-of-sequence placements. There was strong support for a single multi-organ match run to streamline the process before reverting to standard allocation. Questions were asked about whether the committee intended to change current nautical mile distances, which was clarified as a decision that would need to be made by individual organ committees. Additionally, clarification was sought on whether the proposed allocation tables would be integrated into the OPTN Computer System in a way that customizes matches for specific donors or if OPOs would manually select the correct table. The color-coding used in examples was noted as helpful. An attendee noted that the Pancreas Transplantation Committee largely agreed that pancreas allocation was appropriately prioritized, though concerns were raised about highly sensitized pancreas patients who already face disadvantages. There was also a request for periodic assessment of non-utilization and changes in utilization rates. The issue of prioritization between pediatric kidney candidates and kidney-pancreas (KP) recipients was raised, with some advocating for reconsideration of prioritization, particularly for pediatric candidates with donors in the 18-60 age range. It was also suggested that CPRA 100% kidney patients be further subdivided, given the significant differences between 99.6% and 99.99% CPRA levels. Operational concerns were a major theme, as the proposal could significantly impact OPOs, transplant centers, and donor hospitals. The increase in allocation time would put additional strain on donor families, hospitals, and transplant teams, requiring improvements in efficiency to mitigate the burden. Questions were raised about the decision-making process regarding pediatric versus KP priority, as well as the proportion of multi-organ allocations covered by the current proposal. While the intent to standardize multi-organ allocation was . appreciated, concerns remain that overly prescriptive and complex policy changes could reduce efficiency, increase errors, and extend donor case times. Additional guidance is needed to address the operational challenges, and some believe the policy may be premature until a single match run solution is developed. There is also a need to assess the impact on pediatric candidates as the policy is implemented.

OPTN Lung Transplantation Committee | 03/19/2025

The Lung Transplantation Committee thanks the Multi-Organ Transplantation (MOT) Committee for their work on the Establish Comprehensive Multi-Organ Allocation Policy. Overall, the Lung Committee is supportive of the direction of the Request for Feedback.

The Lung Committee emphasized the importance of requiring the OPO to run the allocation plan including the lung match. While lungs may require more time and management prior to allocation, the allocation process should be consistent and should not exclude lung multi-organ candidates from the opportunity to receive a heart or liver along with the lungs based on the time that the allocation plan is run. Additionally, members voiced that if the lungs improved, but were not previously offered, the OPO would have to re-run the allocation plan and reallocate, which could be unnecessarily burdensome. The Lung Committee was asked if the proposed lung Composite Allocation Score (CAS) thresholds would provide appropriate access to transplant for lung multi-organ candidates. The Committee considered the lung CAS thresholds and requests that the MOT Committee ensure that the proposal provides similar access to transplants across all candidate blood types. The Lung Committee was also asked if there should be limits on when a liver could pull lungs from the liver match. The Committee was supportive of allowing candidates with a high (Model for End-Stage Liver Disease) to pull the lungs and commented that this happens rarely, as MELD scores are often low, and CAS high in such situations.

Region 9 | 03/18/2025

Several members expressed general support for the work done thus far, stating that standardization will help improve equity and remove subjective decision making by OPOs. An attendee applauded the committee’s efforts, specifically calling out how this should help pediatric patients with congenital heart disease who need both a heart and a liver because current allocation makes it challenging for them to receive a multi-organ offer. A member had concerns about where kidney classification 6 falls in the allocation tables and recommended moving it up. 

OPTN Membership and Professional Standards Committee | 03/18/2025

The Membership and Professional Standards Committee (MPSC) appreciates the hard work of the MOT Committee in developing this framework and presenting it to the MPSC. The MPSC was overall supportive of the work developed by the MOT Committee, providing some comments and observations.

When considering the technical implementation of these allocation tables, a transplant program member felt like some logistical challenges could be mitigated through a more comprehensive technical solution, while an OPO member expressed support for a dynamic match run where the next required offers would be updated as donor organs are offered and accepted. Overall, there was recognition that the solution proposed would improve consistency in allocation to single and multi-organ candidates. In terms of the order of priority, an OPO member commented that this could potentially penalize OPOs who are required to share kidneys with certain multi-organ combinations prior to a kidney-pancreas (KP) candidate and thus result in the pancreas not being allocated in isolation. Members did not express any other feedback on the way the allocation tables prioritize patients.

MPSC members discussed the importance of communication in allocation, especially for reallocation after late declines or other similar events. An OPO member recommended functionality where transplant programs are able to see the match runs that OPOs are allocating from in order for the transplant program to understand that their multi-organ candidate may be bypassed if one of the organs has been accepted by a single organ or other multi-organ combination candidates higher on the match run. The member emphasized that this visibility could improve transparency and help clarify expectations during allocation and reallocation. Since this work accounts for 96% of donors, a member inquired if the remaining 4% of donors should be restricted to single organ allocation to impact system efficiency. While there was not consensus on recommending this for the policy proposal, it could be beneficial to include the MOT Committee’s discussion on the remaining 4% in the final policy proposal. A member highlighted the importance of post-implementation monitoring for potential adverse effects or unintended consequences with emphasis on the impact on the pediatric population.

Overall, the MPSC is appreciative of the extensive work done to date by the MOT Committee and eager to review the final policy proposal.

Region 11 | 03/18/2025

Several attendees commended the committee for addressing multi-organ transplantation while emphasizing the need to not lose sight of high CPRA patients who are difficult to match. Multiple attendees supported standardization of multi-organ transplantation, particularly to help prioritize pediatric transplants, while noting the need to incorporate these changes with the upcoming roll-out of CAS for liver, kidney, and heart. Several attendees strongly supported defined priorities for multi-organ grafts, and one suggested to place all recipients on a single allocation list in order to avoid unnecessary confusion. An attendee questioned where liver-intestine-pancreas patients would fall in the allocation sequence and suggested these combinations should be called out separately. Another attendee expressed concern that kidney-pancreas candidates with 100% CPRA are prioritized lower than kidney-alone candidates with 100% CPRA, noting that outcomes under the safety net have been favorable, and questioned whether access to lifesaving organs should drive priority differently. An attendee asked about the possibility of having all organs matched on a single list, calling it "the dream," while another raised concerns about finding appropriately sized organs for pediatric Status 1B patients. Concerns were raised about whether allocation tables could be automated in match runs, and if not, acknowledged the need for public distribution of the decision tree. One attendee expressed concern about failing to include Kidney Class 6 candidates with Classes 1-5, which could disadvantage vulnerable pediatric populations.

Alpha-1 Foundation | 03/18/2025

Public Comment Submission on OPTN Winter 2025 Proposals

The Alpha-1 Foundation appreciates the opportunity to provide feedback on the Organ Procurement and Transplantation Network (OPTN) Winter 2025 public comment proposals. As an organization dedicated to advocating for patients with Alpha-1 Antitrypsin Deficiency (Alpha-1), we represent individuals who frequently require lung and liver transplants due to progressive chronic obstructive pulmonary disease (COPD), emphysema, and liver cirrhosis.

The Alpha-1 Foundation strongly supports efforts to improve the transparency, efficiency, and fairness of the organ allocation system. We appreciate the opportunity to provide input on these critical issues and look forward to continued collaboration with OPTN to ensure the best possible outcomes for Alpha-1 patients.

Establish Comprehensive Multi-Organ Allocation Policy (Request for Feedback – Ad Hoc Multi-Organ Transplantation Committee) Multi-organ transplant allocation is critical for Alpha-1 patients requiring both lung and liver transplants. We strongly advocate for:

•A transparent and standardized system that prioritizes patients needing simultaneous liver-lung transplants, ensuring fair access to both organs.

•Avoiding unintended disadvantages for Alpha-1 patients who require dual organ transplants but may not meet current urgency criteria in a single-organ system. We note that Alpha-1 patients almost never meet criteria for both organs simultaneously. Typically, patients present with either lung disease and an abnormal liver or liver disease with mild to moderate emphysema. Isolated liver transplants in Alpha-1 patients with emphysema generally result in improved pulmonary function, whereas lung transplants in patients with liver disease tend to have poorer outcomes due to the hepatotoxicity of post-transplant immunosuppressive drugs.

The Alpha-1 Foundation appreciates the opportunity to engage in this process and will continue to advocate for policies that improve transplant outcomes for our community.

OPTN Operations and Safety Committee | 03/18/2025

The Operations and Safety Committee thanks the OPTN Ad Hoc Multi-Organ Transplantation (MOT) Committee for their efforts on the Concepts for Modifying Multi-Organ Policies request for feedback. The Committee acknowledges the complexity of this topic and appreciate the concepts presented and the opportunity to provide the following questions and feedback for consideration.

The Committee posed the following questions for consideration:

• What is the role of these concepts for late turn downs for MOT recipients and the role for that in non-utilization and placement of sometimes difficult organs (i.e. pancreas offers that are intraoperative turn downs)
• The incremental benefits in terms of efficiency and equity that would come from this policy proposal would pale in comparison to all the allocation out of sequence (AOOS) that is happening. How would these concepts fit into AOOS?

The MOT Committee representative responded that these topics tie together. It is not thought the concepts in the request for feedback would change the challenges of late turn downs. This should not increase it, but it will be the same way that members handle late turn downs now. Additionally, it is not believed that the upcoming policy proposal would increase or decrease the AOOS piece.

Region 8 | 03/18/2025

The region supports the committee’s hard work and acknowledged what a complex and tough topic this is. From an OPO perspective, an attendee explained the most important thing is to make sure the final proposal is very clear on who gets the offer over others. And, what happens when an OPO begins allocation, then another organ becomes available that wasn’t initially thought to be viable for transplant, and how to incorporate the newly available organ into the allocation. Another member pointed out that he suspects OPOs amount of time they are actively allocating the organs will increase. Others thought this is important work and needs to be implemented as soon as possible. They acknowledge that OPOs are always in the middle of these type of allocations and it's an uncomfortable situation for them be in. A member institution explained this is a very complex solution for a system that already relies on too many human factors to determine methodology for organ allocation. They support a more standardized approach and suggested the committee build a system that eliminates as many human factors as possible and optimizes performance of the allocation process by utilizing technology and machine learning. An attendee commented that they thought it was reasonable to standardize multi organ allocation, with the intention of prioritizing pediatrics, status 1 heart and liver. Another said that standardization of multi-organ allocation is desirable and the frame-work of the tables presented is transparent.

American Society of Nephrology | 03/18/2025

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University of Arkansas | 03/18/2025

After review of this policy, we support the aim to promote equity throughout the transplant process and appreciate the need for consistent and efficient organ allocation. We understand the complexity of multi-organ allocation and the potential for significant impact on all organ allocation policy and practices. Currently, policy prioritizes multi-organ candidates but fails to address the disparities that occur when single organ candidates do not receive these offers. The main disparity our patient population faces is offers not extended to kidney alone candidates with CPRAs of 100%. We also believe that Kidney-Pancreas (KP) patients should be evaluated in the same way that other MOT patients are. Not giving KP patients the same prioritization for transplant can lead to deterioration in condition and complications with current treatment regimens. We believe that a significant amount of education/resources will be needed prior to implementing any changes to the allocation system to prevent negative patient outcomes or delays in care. Consideration should be given to transplant centers participating in the IOTA model as organ offer acceptance rate is a large part of this model and centers are expected to increase their organ offer acceptance rate year over year. Making changes to the organ allocation practices will impact transplant centers offer acceptance rates and simultaneous integration with the IOTA model may have a negative impact on transplant centers.

NATCO | 03/17/2025

NATCO is grateful for the opportunity to offer feedback to the OPTN Ad Hoc Multi-Organ Transplantation Committee on the development of a Comprehensive Multi-Organ Allocation Policy aimed at promoting equitable access to transplants and ensuring a consistent and efficient allocation process.
In general, there is significant support for standardization in organ allocation across match runs because it helps ensure fairness, transparency, and consistency. However, there are concerns, particularly regarding the potential lack of flexibility in certain cases and the ability to accommodate specific regional or patient needs. A well-designed standardized allocation system should strike a balance between fairness and flexibility, allowing for regional variations and urgent medical cases without sacrificing equity.
Incorporating essential principles such as ethics, medical complexity, risk, and regional differences into the creation of a standardized multi-organ allocation system that ensures fairness, efficiency, and optimal outcomes for patients requiring life-saving transplants.

Vanderbilt Transplant Center | 03/17/2025

On behalf of Vanderbilt Transplant Center, we appreciate the opportunity to provide feedback on this proposal. In general, we support standardizing allocation of multi-organ combinations and promoting equity in access for organ transplant candidates. However, we would like to better understand the operational and logistical implications of this new system. We would also like to see additional data analysis and/or values prioritization exercises (VPE) performed, specifically with regards to both candidate prioritization and evaluating the success of the proposed changes in streamlining allocation. We would support all recommendations that offer higher pediatric priority in any organ group. While it is always a goal to place more organs, there are ethical arguments for pediatric priority. The argument of "Prudential lifespan" suggests that children have the greatest potential benefit yield with a limited resource and that the younger the age of the person needing an organ, the higher the claim to it. There is a utility benefit for prioritizing children as children have superior survival, thereby extending the life-years gained from a donor organ. Additionally, the “maximin” principle states that resources should be allocated to those most vulnerable, giving the maximum benefit to those who have the least.

OPTN Transplant Coordinators Committee | 03/17/2025

The OPTN Transplant Coordinators Committee appreciates the opportunity to comment on the Multi-Organ Transplantation's Request for Feedback: Establish Comprehensive Multi-Organ Allocation Policy. The Committee offers the following feedback for consideration:

•The Transplant Coordinators Committee wants Multi-Organ Transplantation Committee to further prioritize high CAS lung patients.

•The Committee suggested adding options for auto-populating patient information when adding a patient onto another organ waitlist.

Overall, the Committee is supportive of the developments on Multi-Organ Allocation Policy and appreciates the extensive work that has gone into the creation of this request for feedback.

Region 1 | 03/17/2025

There is support for not including high KDPI kidneys in this allocation plan, as they are typically not used in multi-organ transplants. There is also interest in how multi-organ transplants will be managed under continuous distribution. It was recommended that flags be visible for matches involving multi-organ pairs (e.g., liver-kidney or heart-kidney), so that transplant teams know when they are not the primary recipient for certain organs. This would clarify priorities as the organs approach the operating room. An attendee recommended the committee consider the long wait times experienced by pediatric multivisceral candidates when developing the allocation prioritization.

Association of Organ Procurement Organizations | 03/17/2025

AOPO appreciates the opportunity to provide feedback on the Committee’s difficult and important work to develop and “Establish a Comprehensive Multi-Organ Allocation Policy”. Standardizing multi-organ candidate priority is critical to ensuring equity in organ transplantation. Equally important is the implementation of such policies in a manner that leverages technological advancements to ensure optimal, efficient allocation processes for OPO and Transplant Center end-users of the allocation platform. For the purpose of this public comment, AOPO will refrain from opining on the accuracy of medical expertise in determining the actual priority of allocation and instead comment on the allocation complexities this new Multi-Organ Allocation policy is attempting to address.

AOPO is thankful the MOT Committee has heard feedback from the community regarding the increasing complexities of organ allocation and the challenges these complexities create for OPO personnel. The donor-specific allocation plan is helpful, but it creates additional steps within the difficult allocation process, which could increase complexity and risk for confusion or error. A separate donor-specific allocation plan also seems elementary compared to the technology now available. How could the OPTN utlize? leverage? evolving technology to make allocation even more efficient?

AOPO suggests evaluating technological capabilities to generate a more intuitive match run system that benefits the end-users of the system. Consider having the donation allocation process for a single donor actually embedded within a single donor match run. Study the efficiencies created by the development of a sole allocation match run for all of the organs the OPO indicates it will be allocating. The donor’s single match run would prioritize the offer/allocation priority of all organs within it, utilizing policy priority requirements. As organs are placed for transplant, that donor’s single match run could update real-time creating process efficiencies and lessening the risk of issues and mistakes.

Again, AOPO extends our acknowledgement of this challenging work and appreciates the MOT Committee’s efforts in improving the equity and efficiencies of the system.

Anonymous | 03/15/2025

OPTN has a difficult task to develop measures to optimize organ utilization and achieve equitable access. Because a deceased donor organ's viability is limited, time is of the essence if there is any hope to achieve both goals. Using IT to develop a streamlined, standard approach across the network will hopefully accelerate the match process to the point where no viable deceased donor organ is wasted and the transplant needs of many more candidates are met.   

I am concerned about lower status candidates who also have a time sensitive transplant need. For 6 years I steadfastly followed a heart failure treatment regimen to keep my failing organ viable. My success made me a lower status candidate when evaluated for transplant. I received a transplant, but I wish to advocate for others in a lower status while on the waiting list - patients who manage limitations and risks of having an LVAD or being on infused milrinone to keep them alive by once again faithfully following all medical guidance. 

A track record for demonstrating adherence to pre-transplant regimens would seem to be a critical, positive factor for post-transplant survival. If we can improve the allocation system to protect against the wasting of viable organs, this increases the chance for deserving lower status candidates to get transplants before they are too old to have a long-term benefit from the transplant.  

Thank you for the opportunity to comment on these important proposals. Success in improving the allocation process to address more needs is best accomplished when all participants in the organ donation and transplant process are consulted. 

UW Organ and Tissue Donation | 03/14/2025

UW Organ and Tissue Donation appreciates the committee’s extensive work in creating a system that balances a wide range of needs. Our internal process closely aligns with the allocation priorities outlined, and we value how this proposal supports the placement of every organ a donor has to offer—including those that may only be accepted by programs performing multi-organ transplants such as kidney-pancreas. We do, however, seek clarification on several points: (1) when exactly is an OPO considered to have ‘completed the plan’ and able to revert to standard match runs; (2) how are donor family time constraints or hemodynamic instability addressed within these proposed procedures; (3) what happens if an organ transitions from ineligible to eligible mid-allocation—can we continue without losing prior progress; and (4) if an organ is declined at cross-clamp, does reallocation return to the normal match process post-plan? Thank you for considering our questions as you refine this proposal.

Region 2 | 03/14/2025

There is strong support for improving multi-organ allocation policies to ensure fairness and clarity. Concerns were raised about the complexity of the proposal, particularly regarding how allocation staff will interpret and apply it, especially in urgent situations. There were calls for visual prompts or system guidance to aid decision-making. Attendees expressed concern that pediatric kidney-alone candidates may be disadvantaged compared to kidney-pancreas (KP) candidates. There is a need for safeguards to prevent pediatric patients, particularly those on dialysis or highly sensitized, from losing access to well-matched kidneys due to prioritization of multi-organ recipients. Suggestions included establishing criteria that allow pediatric candidates to be prioritized over adult KP recipients in certain cases. Several attendees emphasized the ethical concerns around how match runs are ordered and the importance of consistent oversight of OPO allocation practices to prevent unintended disadvantages for certain candidates. There was broad support for the Multi-Organ Transplantation Committee to ensure equitable allocation across organ groups and maintain ongoing updates to policy. The project was praised as a strong step forward in addressing a complex issue, with appreciation for the IT and policy efforts required. However, the committee was urged to develop a specific pathway for pediatric patients to ensure they are not disadvantaged under the new allocation framework.

American Society of Transplantation | 03/13/2025

The American Society of Transplantation (AST) generally supports the principles outlined in the request for feedback, “Establish Comprehensive Multi-Organ Allocation Policy.” Efforts to standardize multi-organ allocation across the transplant system are needed to balance equity and efficiency when allocating organs.

In addition to equity and efficiency, post-transplant graft survival (utility) is also a critical factor in organ allocation. Knowing that the ad hoc Multi-Organ Transplantation Committee considered it during their deliberations, the AST recommends that the OPTN specifically addresses post-transplant survival and the rationale for its decisions related to post-transplant survival in any future multi-organ allocation proposal to facilitate a clear understanding among the community.

The OPTN should categorize simultaneous pancreas-kidney (SPK) transplants separately from other multi-organ transplants involving a kidney because utility is generally enhanced with SPK transplants. Separately, pediatric patients should be prioritized above adult kidney-pancreas candidates due to excellent outcomes, risks to growth and development with long-term chronic kidney disease in children.

The AST supports prioritizing highly sensitized and prior living donor kidney candidates above most other groups as these patients are few in number, and highly sensitized candidates have low access to transplant. The AST also agrees with adding the extra match run classifications for donation after brain death donors younger than 11 years of age with a KDPI of 0-34%, as outlined in Figure 11.

The AST agrees with the justification for liver and heart allocation sequences based on medical urgency, but there are concerns about automatically allocating kidneys to these patients when the patient is also listed for a kidney. This is not justifiable on medical urgency grounds because the medical urgency for the simultaneous liver-kidney transplant (SLiK) or simultaneous heart-kidney transplant (SHK) is driven by liver or heart disease, not kidney disease. This is especially pertinent in the era of “safety net” allocation when the kidney disease can be remedied post-transplant in a timely fashion. Utility considerations for multi-organ transplants involving kidneys are important because the high MELD SLiKs and status 1 SHKs are associated with high kidney graft primary nonfunction rates (DOI: 10.1097/TP.0000000000003310 and DOI: 10.34067/KID.0000000000000365). To guide future policy to avoid kidney graft losses, the AST suggests the OPTN analyze the rates of kidney graft loss in multi-organ transplants to help determine where to set thresholds for including the kidney in a multi-organ allocation, i.e., identify patient factors that indicate the patient is too sick for a kidney graft to survive and create appropriate “safety net” opportunities for kidney allocation to these recipients.

As lung transplant allocation has undergone major changes with the lung composite allocation score (CAS), the interaction between CAS-based prioritization and multi-organ allocation should be closely monitored. Are there specific protections in place to ensure that lung transplant candidates—particularly those requiring lung-kidney or lung-liver transplants—do not face unintended disadvantages due to multi-organ allocation prioritization? Missing from this analysis is clarity about where typical multiorgan candidates would fall in these rankings. The upcoming policy proposal would also benefit from simulation modeling of the key allocation groups as well as multiorgan candidates to evaluate whether the multiorgan candidates this is supposed to help don’t actually have increased waiting time. The upcoming proposal should also clarify how the CAS thresholds will be determined- using waiting list survival metrics comparable to the others in table 5-1 or some other approach. Also, the committee may wish to consider setting thresholds based on the makeup of the contemporary waiting list (e.g., a CAS percentile) rather than an absolute number to accommodate changes in the composition of the waiting list over time.

This paper outlines prioritizing children above some combined liver-kidney patients. The AST requests data on how many transplants are in each MELD range to see if this is of significant benefit to children. The AST is concerned that the changes outlined in this paper may negatively impact pediatric liver-kidney candidates, who may lose priority relative to pediatric kidney-alone candidates. Many of these patients are on dialysis and need a liver due to metabolic disease, and their resulting PELD scores would put them behind pediatric kidney-alone potential transplant recipients. The AST requests that the OPTN consider alternatives to ensure pediatric liver-kidney candidates are appropriately prioritized.

In response to specific questions included in the section “Considerations for the community:”

3. The AST would like to see better candidate classification for pancreas and SPK candidates, given additional priority to highly sensitized and pediatric candidates similarly to how it is done for kidney-alone candidates.

4. The AST is generally in favor of the allocation tables, with the following suggestions for improvement:

• In light of the similarity between SPK and kidney-alone transplants on utility grounds, we favor moving pancreas/SPK up the allocation table to where the Kidney Classes are, and inserting SPK/pancreas offers with kidney offers within each class. E.g.:

o Pancreas or KP Class 1: 0-ABDR mismatch; cPRA>80%; 250NM

o Kidney Class 1: 0-ABDR mismatch; cPRA=100%; 250NM

o Pancreas or KP Class 2: cPRA=100%; 250NM

o Kidney Class 2: cPRA=100%; 250NM

o Pancreas or KP Class 3: 0-ABDR mismatch; cPRA>80%; Nation

o Kidney Class 3: 0-ABDR mismatch; cPRA=100%; Nation

• In light of the high morbidity of kidney disease in pediatric candidates, and opportunity for high utility gain, we support moving Kidney Class 6 (pediatric) up to the highest priority.

• Patients who are in Kidney Class 7 are medically urgent due to complication of kidney disease and are conceptually equivalent to the high-medical urgency heart and liver patients. We therefore support moving them to just below Liver Class 1 and Heart Class 1 to reflect this medical urgency.

5. The AST supports multi-organ offers availability for all organs. Currently patients with end-stage kidney disease and another end-stage organ disease frequently wait years without a chance of transplant because of insufficient priority for the other end-stage organ disease. A modification would include extra priority for such patients based on kidney wait time.

6. The AST believes that pediatric pancreas and kidney candidates should be prioritized further, and made the suggestions above in response to question number four in consideration of moving pediatric pancreas and kidney candidates to the highest priority.

10. Yes

11. Yes

12. In light of the similarity between SPK and kidney-alone transplants on utility grounds, we favor moving pancreas/SPK up the allocation table to where the Kidney Classes are, and inserting SPK/pancreas offers with kidney offers within each class. E.g.:

o Pancreas or KP Class 1: 0-ABDR mismatch; cPRA>80%; 250NM

o Kidney Class 1: 0-ABDR mismatch; cPRA=100%; 250NM

o Pancreas or KP Class 2: cPRA=100%; 250NM

o Kidney Class 2: cPRA=100%; 250NM

o Pancreas or KP Class 3: 0-ABDR mismatch; cPRA>80%; Nation

o Kidney Class 3: 0-ABDR mismatch; cPRA=100%; Nation

13. In light of the similarity between SPK and kidney-alone transplants on utility grounds, we favor moving pancreas/SPK up the allocation table to where the Kidney Classes are, and inserting SPK/pancreas offers with kidney offers within each class. E.g.:

• Pancreas or KP Class 1: 0-ABDR mismatch; cPRA>80%; 250NM

• Kidney Class 1: 0-ABDR mismatch; cPRA=100%; 250NM

• Pancreas or KP Class 2: cPRA=100%; 250NM

• Kidney Class 2: cPRA=100%; 250NM

• Pancreas or KP Class 3: 0-ABDR mismatch; cPRA>80%; Nation

• Kidney Class 3: 0-ABDR mismatch; cPRA=100%; Nation

14. The AST feels that pediatric pancreas and kidney candidates should be prioritized further, and made the suggestions above, specifically in moving pediatric pancreas and kidney candidates to the highest priority.

15. Yes. These kidneys can still be good options for the proper adult recipients.

American Society for Histocompatibility and Immunogenetics (ASHI) | 03/13/2025

The American Society for Histocompatibility and Immunogenetics (ASHI) and its National Clinical Affairs Committee (NCAC) appreciate the opportunity to provide feedback on the proposal for establishing a comprehensive multi-organ allocation policy and are in support of the proposed implementation. Instituting such a policy and creating standard practice promotes greater efficiency within the allocation process, and ensures that access to transplant remains equitable.

OPTN Heart Transplantation Committee | 03/12/2025

The OPTN Heart Transplantation Committee (Committee) thanks the OPTN Multi-Organ Transplantation (MOT) Committee for seeking input regarding the Establish Comprehensive Multi-Organ Allocation Policy Request for Feedback (RFF) document. The Committee members generally concurred with the information shared in the RFF concerning the identified allocation sequences assigned to high priority organ candidates. The members agreed that at this time there should not be policy requirements established governing the circumstances by which other organs are able to pull a donor heart as part of multi-organ allocation. The Committee suggested that the MOT Committee compare waitlist mortality rates of the allocation sequences before finalizing a policy proposal. A Committee member stated that heart candidates supported by Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) who are listed at adult status 1 and pediatric status 1A, may have waitlist mortality rates indicating that such candidates should have greater priority than is shown in the proposed allocation tables. Other committee members felt the status 1A liver candidates were appropriately placed as the highest priority. Another Committee member pointed out that within one of the proposed allocation tables, kidney candidates who are prior living donors and within 250 nautical miles of the donor hospital are prioritized ahead of adult heart status 3 candidates who are within 250 nautical miles of the donor hospital. Noting that such status 3 heart candidates are often hospitalized in an ICU setting on life support, there were mixed feelings about placing this medically urgent group below the kidney recipients with an access to care issue.

OPTN Liver & Intestinal Organ Transplantation Committee | 03/12/2025

The Liver & Intestinal Organ Transplantation Committee thanks the Ad Hoc Multi-Organ Transplantation Committee for their efforts on the request for feedback, Establish Comprehensive Multi-Organ Allocation Policy.

The Committee supports the proposed multi-organ allocation tables. The Committee advocates for multi-organ allocation policy that will ensure pancreata are offered to multivisceral candidates prior to single pancreas allocation. Additionally, the Committee agrees that Status 1 intestine candidates should be placed above kidney-pancreas candidates.

The Committee recommends ensuring that the multi-organ allocation tables are easily modifiable to incorporate the eventual switch to continuous distribution systems for all organs.

Anonymous | 03/12/2025

I agree with this change

Amir H | 03/11/2025

I have family I agree with this change

OPTN Transplant Administrators Committee | 03/11/2025

The OPTN Transplant Administrators Committee appreciates the opportunity to comment on the Multi-Organ Transplantation's Request for Feedback: Establish Comprehensive Multi-Organ Allocation Policy. The Committee offers the following feedback for consideration:

•The Transplant Administrators Committee wants Multi-Organ Transplantation Committee to further prioritize high CAS lung patients.

•The Committee suggested adding options for auto-populating patient information when adding a patient onto another organ waitlist.

Overall, the Committee is supportive of the developments on Multi-Organ Allocation Policy and appreciates the extensive work that has gone into the creation of this request for feedback.

Region 4 | 03/11/2025

Attendees provided several suggestions for the committee to consider as they refine the multi-organ allocation policy. There was significant concern raised about how the proposed allocation changes could negatively impact pediatric patients, who are already at a disadvantage in receiving single kidneys. Pediatrics often rank lower on the list for kidney allocation and struggle to access kidneys with a KDPI of 0-35%, frequently losing them to kidney-pancreas (K/P) candidates. Despite computational models suggesting otherwise, the small number of pediatric patients means their disadvantage may not be fully captured in the data. Many children face vascular access limitations, making timely kidney transplantation crucial, yet they are often deprioritized in favor of adult K/P candidates who may not be as urgent. There was broad agreement that a more standardized and transparent policy for multi-organ allocation is necessary, ensuring fairness and consistency across all OPOs. However, concerns remain about whether new policies will be properly enforced, given the increasing frequency of out-of-sequence allocations. Some commented that pancreas transplants are not life-saving in the same way kidney transplants are for pediatric patients, making it even more critical to prioritize children appropriately. They added that simultaneous liver-kidney transplants (SLK) are sometimes used to protect liver transplant metrics rather than to meet true clinical need, leading to the unnecessary use of otherwise viable kidneys. They added that while the ongoing efforts to improve allocation are commendable, the system remains overly complex, particularly for multi-organ transplants. Also, the process needs to be more intuitive for users. Progress is being made, and submitting changes now with the ability to modify based on real-time experience may be the best path forward. However, ensuring that policy changes truly benefit pediatric patients and prevent unnecessary kidney waste should remain a priority.

American Nephrology Nurses Association (ANNA) | 03/10/2025

Attachment

View attachment from American Nephrology Nurses Association (ANNA)

OPTN Organ Procurement Organization Committee | 03/06/2025

The OPTN Organ Procurement Organization Committee appreciates the opportunity to provide input on the OPTN Ad Hoc Multi-Organ Transplantation Committee’s request for feedback and provides the following comments for consideration: 

• The Committee understands that a single-match run is not feasible at this stage. To facilitate the navigation of multiple match runs, the Committee suggests that the IT system provides notifications of when an OPO operator needs to switch between match runs to reduce potential errors and a warning for if an OPO operator attempts to make an offer on an incorrect match run. 
• The Committee supports a policy for multi-organ allocation provided it is clear and easy to follow to ensure compliance. The Committee felt that policy would ensure the multi-organ allocation process was trackable, enforceable, and consistent. The Committee agreed that OPOs should still retain a degree of latitude when allocating certain organs in the event of extenuating circumstances, provided the deviation was well documented. 
• The Committee would like to know more about how the allocation plan might handle changes in the allocation process due to circumstances such as organs previously thought not to be viable for donation becoming viable after primary offers have already been accepted. 

The Committee appreciates the opportunity to provide their feedback on this project and looks forward to further collaboration on the topic with the MOT Committee.  

Region 7 | 03/04/2025

Attendees discussed the process by which the OPO would transition from completing the allocation plan to utilizing allocation tables ordered by descending medical urgency and then reverting to the current policy if necessary. They asked about several key operational issues, including how to account for donor family time constraints, manage scenarios when an organ’s status changes unexpectedly (such as a non-eligible organ becoming eligible), and determine appropriate actions when an organ is declined at the cross-clamp stage. There was a strong emphasis on establishing a robust tracking mechanism to monitor OPO performance and donor management changes during the initial match run phase, even as data collection methods are still under discussion. Attendees also pointed out the importance of addressing the unique needs of pediatric candidates and achieving equity through standardization of the allocation process. Attendees also discussed the potential impact of multi-organ allocation on single-organ processes and noted the challenges of relying on current modeling and historical data to predict these effects. 

Laura Hulse | 03/04/2025

As written, I do not support the allocation prioritization proposed by the Ad Hoc Multi Organ Committee. I would ask the Committee to consider the following and place those kidney-alone candidates added to the waitlist prior to the age of 18, or Kidney Classification 6 candidates, just following Kidney Classifications 1-5 candidates, in the allocation sequence:

According to the SRTR/OPTN 2023 Annual Data Report: Kidney, 60.5% of pediatric kidney transplants were deceased donor transplants. There has been a concerning, persistent decrease in the rate of deceased donor kidney transplant (DDKT) among pediatric waitlist candidates in the past decade – with those candidates who turned 18 by the start of the year with the lowest rate of transplantation among all pediatric candidates.

The OPTN reported that in 2023, 97% DDKT pediatric recipients underwent transplant with a kidney from a donor with KDPI less than 35%, 65% of these children were minorities, and two-thirds of these recipients relied upon Medicare or Medicaid for insurance coverage. According to the Comprehensive Multi-Organ Allocation policy proposal, Appendix 5, Table 5-1: Allocation table for DBD donors aged 18-69 with a KDPI 0-35%; more than half of children were without an organ offer between July 1, 2021 through June 30, 2023.

Failing to include Kidney Class 6 candidates, or those candidates registered prior to age 18 years, with Kidney Classes 1 -5 for order of prioritization at 250NM further disadvantages this extremely vulnerable pediatric population who persist in facing negative cognitive development, linear growth, and psychosocial development due to their childhood-onset ESKD. They may “enjoy” the highest median waitlist survival, but at the cost of a childhood achieving age-appropriate developmental milestones which will handicap their development into young adulthood.

Region 3 | 03/03/2025

Attendees provided several suggestions for the committee to consider as they refine the multi-organ allocation policy. A key concern was raised regarding the 100% cPRA kidney allocation, specifically the need for pre-allocation crossmatching to determine recipient eligibility. The committee acknowledged this point and plans to incorporate it into policy discussions. Another major issue discussed was the weighting of medical urgency in the Composite Allocation Score (CAS), where kidney allocation receives only 25 out of 100 points for urgency, unlike other organs where medical urgency is the primary factor. Attendees questioned how the policy balances the level of sickness across organs, particularly for lungs, given that the CAS is less affected in lung allocation and may impose a cutoff for multi-organ qualification. Regional engagement with stakeholders was encouraged to explore real-world experiences with multi-organ allocation. Standardization of allocation order across match runs received support, though attendees emphasized that technological improvements are necessary to implement this change effectively, as OPOs cannot be expected to manually interpret policies in real-time. The proposed allocation tables were seen as logically aligned with most multi-organ transplant (MOT) cases. However, several operational challenges were identified, including changes in donor criteria, time constraints related to donor stability and hospital or family needs, and inefficiencies in the match run system. Currently, OPOs cannot accept multiple organs for a recipient in the match run system, requiring updates to reflect multi-organ acceptance similar to the kidney/pancreas process. Attendees also suggested enhancements to the OPTN match system, such as color coding or other navigational aids to help OPOs navigate the new allocation tables. Training materials, including real-world allocation examples presented during the meeting, should be incorporated into the OPTN system training to improve implementation. The comments highlighted the need for refinements in policy criteria, system updates to support efficiency, and continued engagement with stakeholders to ensure fairness and practicality in multi-organ allocation.

Region 5 | 02/28/2025

The region supports the proposal, commending the committee’s efforts to standardize multi-organ transplantation (MOT) allocation. Overall, the region agrees with the policy’s direction and supports efforts to create more objective and transparent MOT allocation processes. Key themes include: 

• Need for Standardization: Clear, uniform processes across OPOs and transplant centers will promote consistency, fairness, and equity. Standard allocation tables are a good starting point, and adjustments can be made as data is collected. Alerts and warnings in DonorNet are recommended to support compliance. 
• Pediatric Concerns: Several commenters stressed the need to evaluate and model the policy’s impact on pediatric candidates, particularly kidney recipients. The concern is that high-priority 0-34% KDPI donors, frequently used for MOT, may further limit pediatric access to these organs. Pediatric candidates should be prioritized for pediatric donors, including adolescent donors. 
• Kidney Allocation with Other Organs: The most complex issue appears to be kidney allocation with other life-saving organs (lung, heart, liver). Suggestions include raising the eligibility bar for MOT to ensure only those who truly need both organs are listed, as isolated kidney candidates face long wait times. Liver/kidney listing criteria may need refinement, especially since the safety net and improved kidney treatments have reduced the need for simultaneous transplants. 
• Operational and Performance Considerations: OPOs will need training and support from OPTN for smooth implementation. Center-level factors, such as listing practices and offer acceptance rates, should be considered in policy analysis. 
• Ongoing Monitoring and Adjustments: Continuous evaluation is essential to assess the policy’s impact on different populations, particularly pediatric candidates. The committee should be prepared to make adjustments as needed to maintain fairness and optimize outcomes. 

OPTN Ethics Committee | 02/28/2025

The OPTN Ethics Committee thanks the OPTN Ad Hoc Multi Organ Transplantation (MOT) Committee for its work in developing the request for feedback to establish consistent allocation of multi-organ combinations and is impressed with the comprehensive and thoughtful nature of this sustained, substantive analysis. The Ethics Committee is supportive of this project and this white paper, including the MOT Committee’s endorsement of changes to allocation policy that provide increased support for pediatric patients, to take just one example. The Ethics Committee also appreciates the attention in general given to the promotion of the principle of equity in this white paper.

The Committee provides several considerations and questions for the MOT Committee to address, as it develops and proposes multi organ allocation policy, as a result of the feedback request.

It is important to consider what some of the drawbacks which may result in transitioning to a rigid priority list as detailed in the “multi-organ allocation table” (beginning with Liver Class 1: Status 1A (adult pediatric); 500 nautical miles and ending with Liver class 27 MELD/PELD of at least 29). While this table provides more consistency and standardization in allocating multiple organs, something for which the Ethics Committee applauds the MOT committee, it would be informative to understand any offsets or downsides of adhering to this table. Allocation of human organs is characteristically zero-sum game. Who are the likely winners and losers with this proposed modification to allocation policy (understanding the white paper won’t itself alter current policy)?

It is unclear how this proposal aligns with the trend of more of organs being transplanted out of sequence. It would be helpful to model how allocation schemes offered in this proposal may increase or decrease aggregate organs being allocated out of sequence. The Ethics Committee recently drafted (pending public release) a white paper examining the ethical implications of allocating organs out of sequence and would be interested to understand how potential policy resulting from this request for feedback would allow for richer future analysis on this topic. Also, in keeping with this question of alignment, the Ethics Committee also asks if these new classification the MOT Committee introduces in this white paper coheres completely with the updates to Continuous Distribution across the organs.

The Committee additionally encourages the MOT Committee to consider how multi organ allocation policy can increase system access for those, like highly sensitized candidates, who currently have poor access to transplant. While expedited placement for organs can be beneficial for some patients, many candidates will not benefit due to the necessity of a cross-match. Some on the Ethics Committee raised the concern about how highly sensitized patients receive multiple allocations, as detailed in the proposed multi-organ donor allocation tables and a proposed order of priority in the request for feedback. Highly sensitized candidates, such as a candidate with a CPRA of 100%, should be able to receive additional organs under multi organ allocation, despite being sensitized. Equity, as noted, for those on the waitlist is a main concern for the Ethics Committee (and we are aware this point is not lost on the MOT Committee).

Keith Plummer | 02/20/2025

I agree with all points addressed in this proposal and fully support.

OPTN Kidney Transplantation Committee | 02/20/2025

The OPTN Kidney Transplantation Committee (Committee) appreciates the opportunity to comment on this Request for Feedback. The Committee supports changes to multi-organ allocation policies that promote access to transplant for kidney-alone candidates, particularly pediatric kidney candidates and highly sensitized kidney candidates, and for multivisceral candidates, who are typically pediatric candidates. The Committee supports a standardized policy to promote access to transplant for these populations. The Committee is concerned that under current policy, kidneys are typically allocated to kidney multi-organ candidates prior to being offered to kidney-alone candidates, and that multivisceral candidates do not receive offers very often. The Committee recommends that the Ad Hoc Multi-Organ Transplantation Committee consider how virtual crossmatching can be employed to support implementation of the policy proposal under development, since organ procurement organizations are often asked to send blood samples for crossmatch for multi-organ candidates. There is a finite amount of blood that can be sent for sampling from each donor and the time to transport samples and perform physical crossmatches can potentially delay operating room times and/or run up against donor family timing constraints.

Rajdeep Das | 02/14/2025

The proposed multi-organ allocation policy seeks to establish a standardized framework for organ distribution, ensuring fairness and efficiency in the allocation process. It aims to address key challenges such as ambiguous priority rankings, regional disparities in organ procurement, and resource-intensive allocation procedures. It is a significant step forward and by implementing this policy, the organ distribution system can potentially move toward greater equity and operational effectiveness. However, some potential challenges that need to be addressed are: (1) Implementation Complexity: The proposed system requires significant changes to the OPTN Computer System, risking delays and temporary inefficiencies. Potential solution could be: A phased rollout with training for OPOs and transplant programs can ease the transition; (2) Lack of a Unified Match Run: The proposal does not introduce a single match run, which could streamline allocation. Potential solution could be: Future revisions should explore integrating all organs into a standardized match system; (3) Limited Donor Group Inclusion: High KDPI donors and rare organ combinations are not comprehensively addressed. Potential solution could be: Further data analysis should determine if additional allocation tables are needed; (4) Incomplete CPRA Consideration: CPRA’s impact beyond kidney allocation and on pediatric candidates is unclear. Potential solution could be: Expanded CPRA prioritization and adjusted weighting for pediatric patients can ensure fairness and (5) Risk of Organ Non-Utilization: Prioritizing highly sensitized candidates may increase discard rates. Potential solution could be: A contingency plan should allow flexibility when no suitable match is found.

Oyedolamu Olaitan | 02/02/2025

This is a very important and difficult work, kudos to the Ad HOC MOT committee for the hard work. I support the proposals, but would like to add that for the "DBD donors aged 11-17, KDPI 0-34%", if Kidney Classification 6 (pediatric within 250NM) is going to be placed above Pancreas Classification 4 (P or KP within 250NM); it is important to make a provision in the policy to make a kidney available for the simultaneous pancreas kidney (SPK) recipient in cases where there is no pancreas alone recipient so as to avoid non-utilization of good pancreas. Currently pancreas has high non-utilization rate, which is multifactorial in origin and the Pancreas Committee is working to reduce these, however, the proposal as written is likely to worsen that as most pancreas recipients are SPK, within Classification 4 and mostly utilize pancreas from donors within 250NM. Thanks you for the opportunity to comment.