Promote Efficiency of Lung Allocation
At a glance
In March 2023, lung allocation policy changed to follow a new framework called continuous distribution, where candidates receive a composite allocation score (CAS), which combines many patient and donor factors into one score. While this change has increased lung transplants and reduced waiting time death, it has also unintentionally increased the times for organ evaluation, organ offer response, and organ placement. This paper explains the upcoming release of lung offer filters, proposes the addition of two new donor data fields, and asks for community feedback on additional potential ideas to help improve efficiency.
Proposed changes and feedback requested
- Lung Offer Filters:
- Allows lung programs to apply customized filters so they do not receive offers for donors they would not consider accepting
- Includes filter criteria for: donor type, distance, and maximum/minimum donor age
- Expected to be available early 2024
- Proposed new fields in the OPTN Donor Data and Matching System:
- History of anaphylaxis to peanut and/or tree nut
- Previous sternotomies
- Community feedback requested on other potential system improvements
- Giving programs the option to opt-in to offers from geographically isolated areas (for example: Hawaii, Alaska, Puerto Rico)
- Allowing OPOs who are placing a single donor lung the option to skip candidates who need a bilateral lung transplant
- What it's expected to do
- Provide lung transplant programs with additional tools for quicker decision making
- Start a conversation with the lung transplant community on additional ideas to consider to help OPOs and lung transplant programs operate more efficiently
- Collect new data to help inform potential future lung offer filter criteria
- What it won't do
- Require all lung programs to use lung offer filters
- Allow lung programs to set offer filters for the newly proposed data fields of “history of anaphylaxis to peanut and/or tree nut” and “previous sternotomies”
Terms to know
- Offer Filters: A tool that transplant programs can customize in order to not receive organ offers from donors they would not accept organs from.
- OPTN Donor Data and Matching System: The computer system that focuses on the registration of deceased donors, organ matching, organ offers and placement.
Read the full proposal (PDF)Provide feedback
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.
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.