Addressing the Critical Challenge of Organ Non-Utilization

The Association of Organ Procurement Organizations (AOPO) is addressing the most critical and ongoing challenge within the U.S. organ donation and transplant system – organ non-utilization. We are dedicated to collectively overcoming the hurdles that impede the efficient use of available organs, driving progress in our field, and making the most of every opportunity to save lives.

2023 marked a notable year for organ donation, spearheaded by relentless efforts from Organ Procurement Organizations (OPOs) across the nation. Thanks to these endeavors, we witnessed a 9.6% increase in deceased organ donation, culminating in over 16,000 generous donors and more than 54,000 organs recovered. However, despite these significant strides, only 43,000 of these organs were ultimately transplanted. This glaring discrepancy highlights organ non-utilization as a profound issue in our system.

The organ most affected by this gap is the kidney, which represents the highest demand for transplants in the U.S. Alarmingly, over 8,500 kidneys, or 28% of those recovered last year, were not used for transplants. This is particularly tragic considering that more than 100,000 Americans await a life-saving organ. A significant 63% of those waiting are people of color, many of whom disproportionately await kidney transplants.

An equity report by the National Academies of Sciences, Engineering, and Medicine (NASEM) casts a stark light on this issue, noting the U.S. has a much higher rate of kidney non-utilization compared to other developed countries. For instance, approximately 62% of kidneys not used in the U.S. would likely have found a recipient in France.

This issue has not gone unnoticed. The donation and transplantation community acknowledges the urgent need for reform to facilitate the transplantation of more medically complex organs, as underscored by a recent op-ed from a transplant surgeon in STAT News. The author affirms that organ non-utilization can be attributed to various factors, including transplant center declines due to concerns with organ quality, allocation logistical challenges, and regulatory scrutiny over transplant outcomes.

In response, AOPO has elevated organ utilization to a top priority, aiming for 50,000 organs transplanted annually starting in 2026. To support this goal, AOPO is taking several actions:

  1. advocating for regulatory and financial reforms to increase the use of organs from older and medically complex donors,
  2. informing stakeholders about policy reforms aimed at increasing organ utilization,
  3. striving to align performance metrics between OPOs and transplant centers performance measures to maximize the use of available organs for transplant,
  4. supporting performance metrics for transplant centers that include organ offer acceptance rates, and
  5. ensuring transparency and accountability regarding organ utilization across all system partners.

The entire donation and transplantation community has also responded with initiatives such as the Centers for Medicare and Medicaid Services (CMS) End Stage Renal Disease Treatment Choices Learning Collaborative (ETCLC) which aims to decrease the nonuse rate of all procured kidneys. Additionally, the Organ Procurement and Transplantation Network (OPTN) Expeditious Task Force is crafting recommendations on ways to increase the number of donated organs used for transplant and increase the efficiency of the organ placement process.

OPOs are actively participating in these initiatives to address the crisis of organ non-utilization. This commitment is vital not only to our mission of honoring the gift, but also to ensure the recertification of OPOs so they can continue their life-saving work. Notably, under the new CMS performance metrics, OPOs are evaluated on a “Transplant Rate,” which hinges on transplant centers’ rate of organ acceptance. This regulation could lead to the potential decertification of up to 42% of nonprofit OPOs in 2026, while the question of how to mitigate organ non-utilization remains unanswered. CMS has yet to outline how the system would adapt to such significant losses.

The challenge of organ non-utilization poses a significant risk, not just to patient lives but to the very framework of organ donation and transplantation in the U.S. As we navigate these complexities, stakeholder support and collaboration are crucial to implementing solutions which maximize organ donation opportunities and ensure the utilization of viable organs capable of saving lives.

Steve Miller, MBA, CAE

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