Deceased organ allocation: deciding early when to move fast

The deceased donor waiting list for kidneys to transplant is congested: offers, which take time to evaluate, are often rejected, while cold ischemia time accumulates.

 Here's a paper just published in Transplantation, in which we suggest new ways to detect organs that will be hard to match, and which might therefore be expedited through the allocation process (to get more quickly to patients who will accept them).

Insights From Refusal Patterns for Deceased Donor Kidney Offers, by Guan, Grace MS1; Neelam, Sanjit MS2; Studnia, Joachim MS2; Cheng, Xingxing S. MD, MS3; Melcher, Marc L. MD, PhD4; Rees, Michael A. MD, PhD5,6; Roth, Alvin E. PhD7; Somaini, Paulo PhD8; Ashlagi, Itai PhD1
Author Information
Transplantation ():10.1097/TP.0000000000005434, May 21, 2025 

"Background.
The likelihood that a deceased donor kidney will be used evolves during the allocation process. Transplant centers can either decline an organ offer for a single patient or for multiple patients at the same time. We hypothesize that refusals for a single patient indicate issues with individual patients, whereas simultaneous refusals for multiple patients indicate issues with organ quality.

Methods.
We investigate offer refusal patterns between January 1, 2022, and December 31, 2023, using Organ Procurement and Transplantation Network data. We aggregate refusals at the same timestamp by a center and define a multiple patient refusal as >1 or >5 patients simultaneously refused. We report the refusal codes associated with single and multiple patient refusals and the nonutilization rate after receiving single and multiple patient refusals by cross-clamp.

Results.
Patient-related refusal reasons are more commonly single patient refusals, whereas organ-related refusal reasons are more commonly multiple patient refusals. Multiple patient refusals before cross-clamp are associated with nonutilization, but single patient refusals are positively correlated with utilization. The nonutilization rate was 28% for organs without pre-clamp refusals, 35% with a single center sending a multiple patient refusal, but only 12% with a single center sending a single patient refusal.

Conclusions.
The risk of nonutilization can be assessed early in the offering process based on the number of single and multiple patient refusals received by a specific time (e.g., cross-clamp). Understanding refusal patterns can guide the development of transparent protocols for accelerated placement."