The Buzz This Week
Last week, both the U.S. Senate and House of Representatives overwhelmingly passed legislation to overhaul the country’s current organ transplant system. The bill is now with President Biden, who is expected to sign. The bill authorizes a competitive process for managing the Organ Procurement and Transplantation Network (OPTN). Since 1984, operation of the OPTN has been solely conducted by the United Network for Organ Sharing (UNOS), an organization that oversees more than 250 transplant centers and 57 organ procurement organizations (OPOs). Each OPO operates in a defined geographic region, and patients do not have a choice which OPO they use.
A 3-year investigation by the Senate Finance Committee found numerous mismanagement concerns, system failures, and opportunities for improvement. Specifically, the report cited concerns about lack of accountability and proper oversight of OPOs by UNOS. Numerous transplant errors, including blood type mismatches and improper screening, led to transplant recipients receiving organs that their body rejected or caused disease. Between 2008 and 2015, nearly 250 people who had received transplants developed cancer or other disease from the receiving organ, and 70 people died as a result. Despite numerous reports and concerns over OPO quality and safety standards, UNOS has only once recommended an OPO lose certification. There were also numerous transport errors leading to organs being discarded, lost in transit, or never collected. Data shows that in 2020, 21% of kidneys (which makes up nearly 90% of the over 100,000-person waitlist for organ donation) were not transplanted.
Why It Matters
Demand for organ transplants continues to rise. While the United States performed a record 42,887 transplants in 2022, with more than 100,000 people on the list, many still die waiting for an organ. A more efficient system with stricter safety and quality guidelines could help to substantially increase the number of successful organ transplants.
Better oversight of OPOs is a clear need for the new organ transplant managing entity. In 2019, the Centers of Medicare and Medicaid Services (CMS) issued strict, new OPO performance metrics. OPOs have until 2026 to meet all standards or risk loss of certification. Currently, more than one-third of OPOs do not meet standards and have faced no penalties. The new oversight body must ensure safety and quality standards are met and apply appropriate consequences if they are not.
Technological updates will also be vital to managing OPTN. The system and software utilized by UNOS to manage transplant data and tracking is out of date. A technology overhaul would eliminate manual entry, reduce system failures, fix errors in programming, and improve logistical hiccups, all leading to a more efficient transplant system.
Numerous racial inequities exist in the current organ transplant system. The average wait time for Black patients to get an organ is 1 year longer than for white patients. Black patients are more likely to develop kidney and heart disease but are less likely to be placed on the waitlist and receive kidney and heart transplants. In 2022, Black patients made up 28% of the transplant waiting list yet received only 21% of transplants. Changes to primary care may help to reduce disparities—including reducing time to referral for transplant evaluation and development of care teams that can communicate in preferred language and provide more convenient appointment times.
Additionally, removing race adjustments to diagnostic blood testing is vital. Two key blood tests for measuring kidney function, estimated glomerular filtration rates (eGFR) and urine albumin-creatine ration (uACR), have historically been adjusted for Black patients from an assumption that Black people have higher creatine levels, delaying kidney disease diagnosis. Data collection and analyzation of transplant processes and outcomes by race and demographic characteristics can help to measure and track improvements in equity.
Changes to OPTN may be coming very soon. The current contract with UNOS expires September 30 of this year. It is unclear the exact details planned for the redesign of OPTN, but accountability for OPO performance, technological improvements, and a focus on equity will be vital.
Feds Propose to Overhaul Organ Transplant System
Congress Authorizes Overhaul of Troubled Organ Transplant System
Editorial advisor: Roger Ray, MD, Chief Physician Executive.