Realizing the Promise of Equity in the Organ Transplantation System

Individuals in need of a transplant of a deceased donor organ are added to a waiting list. Transplant waiting lists prioritize patients based on medical urgency and other factors, although the measures used to determine urgency are different for each organ.

Most organ allocation systems assign organs to patients who are determined to have the highest likelihood of long-term graft survival. This system may lower the total number of lives saved because it allocates higher-quality organs to healthier patients while sending lower-quality organs to more medically urgent transplant patients. It also disproportionately allocates high-quality organs to white, wealthy, and abled transplant patients, since those patients are generally healthier when they enter the transplant system. Finally, even relatively healthy patients may have a higher chance of survival if they receive a lower-quality organ immediately rather than waiting for a high-quality organ.

Patients’ levels of education and health literacy, which correlate closely with ethnicity and socioeconomic status, strongly impact their ability to understand and navigate the organ transplantation process.

Kidneys are allocated to patients based on the amount of time they have spent on the waiting list. Because wealthy, white, and/or abled patients have better access to primary care, they can get diagnosed and put on a waiting list earlier, giving them an advantage in obtaining a kidney.

The success of the U.S. deceased donor organ transplant system depends on the generosity of individuals and their families who, at the time of death, make the decision to donate organs to someone they have never met. Without these donations, organ transplants would not be possible.

Donation after circulatory determination of death (DCDD) provides an opportunity to increase the number of donated and transplanted organs, but presents some challenges not present in donation after neurological determination of death (DNDD). These challenges include higher cost per organ and increased risk of complications during or after transplant. New technologies such as normothermic perfusion have shown promise in reducing the likelihood of complications in DCDD organ transplants, and have opened up the possibility of using organs from donors with Hepatitis C, HIV, or COVID-19.

Donor Care Units (DCUs) are facilities built and managed by organ procurement organizations, community hospitals, or transplant centers to recover organs from deceased donors. DCUs provide several benefits to the organ transplantation process: they provide space for donor families, open up space in ICUs for other patients, allow donations to be managed by staff with experience in the donation process, provide stability in setting operating room times for procurement operations, and can procure more organs at a lower cost per organ than donations from hospitals.

Once a prospective recipient is found for a donated organ, an organ offer is sent to the recipient via the care team at their transplant center. The decision to accept or reject an organ offer is usually made by the transplant center, without the patient’s knowledge or input. One study found that individuals who die on the kidney transplant list had an average of 16 kidney offers rejected by their transplant center. These rejections also mean that some organs are not used at all, resulting in the waste of a finite and precious medical resource.

Shortages in trained staff, available rooms, or other limited hospital resources can delay organ procurement or transplant surgeries. Understaffing on Fridays, Saturdays, and Sundays leads to a statistically measurable “weekend effect” in which organs that become available on those days are less likely to be procured, accepted, or transplanted.