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Transplant Centers Resource Center
nephrology news and issues ByAndrew Klein, MD, MBA
Fact checked byRichard Smith August 16, 2023
After 37 years as a liver transplant surgeon, and after performing more than 1,000 surgeries, I have come to appreciate the successes and challenges of the U.S. organ donation and transplant system.
I transplanted a liver in a young pregnant woman dying of acute liver failure who recovered and gave birth to a healthy child and then to another child. Three years after performing my first transplant, I went scuba diving and was 100 feet below the ocean surface with that same person, who was now my instructor. When we first met, his life was in my hands, but suddenly mine was in his. The circle of life was never more apparent to me.
But I have also watched transplant centers reject organs because they came from someone who was not in optimal health — people with obesity or diabetes or who had long-term cigarette and alcohol abuse — only to learn too late that their organs appeared healthy and transplantable. And I have waited hours for an organ to arrive before finding out it was mistakenly sent to the wrong hospital, putting my patient’s life on the line as precious time was spent getting it to the right place and then safely transplanting it just in time.
A successful system
The United States has the most sophisticated and advanced organ donation and transplant system in the world. No other country comes close to performing as many transplants as the U.S., which had more than 48,000 transplants in 2024 and surpassed more than 1 million transplants ever performed in 2022.
Importantly, the system is improving every day. There has been a 55% increase in transplants during the past decade, and fewer people are dying while waiting for a transplant.
However, with more than 100,000 people on the waitlist, there is certainly room to make the U.S. system stronger.
In 2023, the Securing the U.S. Organ Procurement and Transplantation Network (OPTN) Act was signed into law, which enables the Health Resources and Services Administration, which oversees the OPTN, to modernize the current system. Modernization plans include restructuring the way the system is managed, from one federal contractor to a multi-vendor, multi-contract set up. The goal is to make the system work even better, with fewer patients waiting or dying while waiting for a lifesaving organ. A goal we can all agree on.
But changes — especially big, systemic changes — take time. I have seen again and again how little time transplant patients have, which is why action must be taken now.
That is why the United Network for Organ Sharing (UNOS) is driving reforms forward, educating and informing law and policymakers about the lifesaving changes that can be implemented right now.
Reforms needed
UNOS has managed the OPTN under contract with the federal government for almost 40 years and is pushing for these reforms because they are outside of the scope of what the OPTN contractor can do.
For starters, we can improve efficiencies and get organs, primarily kidneys, to patients faster by allowing them to be flown in the main cabin of commercial airplanes, as was the case prior to 9/11. Airport security and airline policy changes regulated donor organs to fly in the cargo — yes, next to your suitcase — causing delays and risking the viability of the organ. It is estimated 2.5% of organs go unused due to transportation issues. By allowing kidneys to fly in the main cabin, more organs will be handled with care, avoiding delays, damage and loss, to help people get the transplants they need.
A U.S. Department of Transportation and Federal Aviation Administration working group has brought stakeholders together to address this issue and is expected to provide a recommended solution this summer. As a supporter of the working group, UNOS is pushing for this common-sense solution to bring organs back above the wing.
Another way to help get donor organs safely to their destination is by mandating tracking for organs in transit. I once waited more than 3 hours for a liver to arrive so I could transplant it for a critical care patient when it was coming from a hospital 20 minutes away. A miscommunication resulted in the organ being sent by courier to a different hospital. As a surgeon, I cannot stress how much every minute counts when it comes to an organ’s viability. There is simply no time to waste. Thankfully, the hospitals were close enough that we were able to get the organ to our hospital and successfully transplant it, saving my patient’s life.
A national, centralized tracking system for organs in transit could have prevented this from happening that night. This would provide key transplant professionals maximum, real-time visibility into the location of lifesaving organs, and would have given me and my surgical team the ability to locate the organ as soon as we felt too much time had passed. A transportation tracking system would also enable investigations of organs that were lost in transit, which is important when implementing improvements.
Additionally, a way to help more people get the transplants they need is by mandating automated donor referrals. Successful transplants depend on quick and accurate information-sharing with organ procurement organizations (OPOs), nonprofits that recover organs from deceased donors. This information is often transmitted manually and by overworked hospital staff, increasing the risk for misinformation. Automated referrals would ensure OPOs are automatically alerted about a potential organ donation when a dying patient meets predetermined clinical criteria. This would lead to more lifesaving transplants and the honoring of every gift of life.
And finally, we need to align incentives for transplant hospitals and physicians to accept and transplant hard-to-place organs. Transplant programs are constantly evaluated on how many positive outcomes they have, and with payments, insurance contracts, program status and center of excellence designations connected to those evaluations, it is difficult for centers to accept organs that they deem “less than perfect” or for high-risk patients. Oversight of transplant programs’ performance is a necessary element for ensuring wise stewardship of a limited supply of lifesaving organs and for reinforcing public trust in the system. However, we must apply the performance standards in a manner that does not serve as a disincentive for expanding the donor pool.
A Medicare policy change could encourage more hospitals to develop the expertise needed to accept less-than-perfect organs, which would prevent thousands of deaths each year.
Call to action
These reforms will make the U.S. organ donation and transplant system more efficient, more reliable and stronger. Put simply, they will save lives. I hope you join me in urging congressional leaders and policymakers to act on these lifesaving reforms to make America’s world-renowned donation and transplant system even better.
For More Information:
Andrew Klein, MD, MBA, is chief medical officer for the United Network for Organ Sharing. He can be reached at newsroom@unos.org .
Disclosure: Klein reports he is a chief medical officer for the United Network for Organ Sharing.
Published by: nephrology news
Sources/Disclosures: Disclosures: Klein reports he is a chief medical officer for the United Network for Organ Sharing.
