Last fall (November 24, 2017 to be exact), the United Network for Organ Sharing, or UNOS, revised a policy that allocates lungs for lung transplant procedures. Changes to the liver policies are also being considered. Great news, right? Maybe? Since this isn’t the easiest thing to understand, we thought we’d break it down – what does this all actually mean?
We can feel your enthusiasm already – who doesn’t love a good policy analysis blog piece, right? Regardless, these changes are important to understand as advocates for donation and for anyone on the waitlist, whether they will affect the chances of receiving a transplant in the state or not.
Donation Service Area Map, Maryland. Blue: The Living Legacy Foundation of Maryland service area. Green: Washington Regional Transplant Community service area. Includes DC and Northern VA.
A Little Background
Before we dive in, let’s get some terms and background out of the way first. To start, The Living Legacy Foundation of Maryland (that’s us!) is what’s known as an “organ procurement organization,” or an OPO. We are responsible for the recovery of deceased donor organs within a “designated service area,” or DSA. These DSAs are then grouped into “regions” by the United Network for Organ Sharing (UNOS). Using factors such as blood type, height, weight, and other matching criteria, UNOS uses a computerized network, governed by “allocation policies” to match donated organs with transplant candidates. The allocation policies (each organ has its own) lay out the process for matching these organs with where they will be the most successful and save as many lives as possible. The goal of these policies is to ensure organs are matched fairly so that the organ goes to the sickest matching patient, regardless of the patient’s wealth, race, gender, age, location, or social status.
UNOS Region Map, according to UNOS.org
What Was Wrong With the Old Policy?
Now, onto the policy itself. The previous lung and liver allocation policies operated on a “local priority first” premise. Basically, when lungs or livers were being matched, they were first offered to the sickest patients within a geographic proximity first. If there were no matches there, they were then offered to a larger geographic region, and then offered nationally. Advantages to this system included decreased risk to the organ over long transportation distance, less of a burden on OPOs and their staff to travel, and an increased sense of community for donor families and recipients knowing that the organs came from and were going to someone geographically close to home. Sounds great, right?
Unfortunately, this system had a big problem. Policy makers became aware that, for a number of reasons, certain donor service areas had severe shortages of organs, while service areas next door did not. This led to a big geographic disparity in how sick a patient needed to be before receiving a transplant. Very sick patients in one area would have to wait longer than less sick patients in other areas. Not only is this a little skewed ethically, this premise is also in conflict with the Final Rule of the National Organ Transplant Act (NOTA), the governing legislative language describing organ allocation policies passed by Congress in 1984. When this problem was brought up to legislators, they approached UNOS, and the process of changing the policy began.
Making Changes for the Better, Right?
So once the problem was identified, the work began to fix it. First, the new policies minimize the “local first,” provision, where organs are offered within donor service area or region first. Instead, the geographic proximity that lungs are matched on was expanded; it is now a 250 nautical mile circle around where the organ is recovered (the proposed new liver policy will expand to 150 miles). This gives many of the donor service areas with organ shortages access to organs from other regions and should allow for the sickest people overall to receive transplants, instead of just the sickest people within a particular service area. Many believe this will be the best way to ensure fairness and equitability in the transplant process. The goal is to minimize roadblocks to receiving a transplant that are out of a waiting list candidate’s control.
Examples of 150 nautical mile parameter that livers would be matched on. www.UNOS.org
Now, as with any change, there are both positive and negative effects that come with it. Here at The LLF, we are seeing an increase in the distance of travel for our clinical teams to recover and transplant organs. While the recoveries and transplants before were mostly focused in the state, our teams are now more consistently traveling to a much wider area to recover organs for our local recipients. This, of course, increases the resources the organization and transplant centers must use to perform the procedures, as well as increases the risk of accidents to the organ and/or to the passengers while traveling.
There is also the “sense of community” factor. Are people more willing to register as organ donors knowing it is going to someone in their community or state? Or are people more focused on saving lives wherever their organs are needed? Well, you tell us. Seriously, we’re asking! We would love to hear your thoughts on this in the comments.
Time Will Tell
Pros and cons aside, at the end of the day, our mission, like the mission of all OPOs, is to save lives through donation and transplantation. Despite organizational challenges the policy changes may bring, overall they are expected to have a positive impact on the number of lives saved, and that’s something we’ll always be a fan of. We’re fortunate that here in Maryland, thanks to generous donors and dedicated healthcare institutions, we already recover and transplant a high number of organs. This policy allows us to work more frequently with the many great transplant programs around us and serve even more donor families and transplant recipients. This new policy should ensure that those who are sickest get transplanted first, meaning less people will die on the waiting list, meaning more opportunity for saved lives.
This new policy is going to be evaluated again in November 2018, to determine its success. There are obviously many variables with every transplant case, but the hope is that this change in policy will give everyone waiting a more equal chance at the gift of life. However it plays out, The LLF, our transplant center partners at University of Maryland Medical Center and Johns Hopkins University, and the entire donation and transplantation community remain committed to saving as many lives as possible through organ, eye, and tissue donation.
McRann, D. Liver and Lung Allocation OPTN Policy Changes [PowerPoint slides]. Retrieved from The Living Legacy Foundation Ethics Committee Meeting.