Over 1,200 people died in the last 5 years after being skipped over as they approaching the top of an organ transplant waiting list, The New York Times highlighted in a recent article, “Organ Transplant System ‘in Chaos’ as Waiting Lists Are Ignored.” Many were waiting for kidneys.  

ASN, which, for years, has been advocating for more transparency and maximum transplant access as well as reforms to address out-of-sequence kidney allocation, has established a Transplant Policy Committee to lead ASN’s transplant-related policy efforts. 

"ASN has been calling attention to these trends in allocation for the last two years, particularly in comments and communications with OPTN and HRSA leadership," said ASN Transplant Policy Committee Chair Roslyn B. Mannon, MD, FASN. "While the number of kidney transplants in the United States has continued to rise in recent years, which is extraordinary and commendable, the current kidney allocation system is not functioning efficiently, transparently, or fairly. I know we can do better as a community, and ASN is committed to being a constructive contributor working towards comprehensive solutions." 

Resolving the challenges with the kidney allocation system including the growing discard rate and number of out-of-sequence offers is a top ASN transplant policy priority in 2025. Evidence is mounting that the matching system can function more optimally than it does at present. For example:

• 1 in 4 kidneys recovered for transplant go unused (discarded) despite evidence that many would have benefitted patients relative to dialysis 
• 1 in 5 kidneys are allocated out of sequence (e.g. transplanted into a candidate that was not first in line according to the waitlist)
• Fewer than 1 in 5 kidneys are transplanted into the top-ranked candidate on the waitlist
• 17 kidneys have been declined, on average, on behalf of a person who dies waiting for a transplant (typically without their knowledge), 100% of which were successfully transplanted into another candidate lower on the waitlist 

With the increased attention The New York Times article is bringing to these challenges, identifying and highlighting solutions will be an even bigger area of focus for the Transplant Policy Committee in the coming months. 

No single fix can resolve these challenges overnight; a holistic, long-term approach is needed. Among the recommendations the society has already made to begin to mitigate some of the allocation-related issues are:

• Initiate work on a long-term fundamental overhaul of allocation system and optimizing the matching system, recognizing this complex process will take years of work 
• Enforce existing OPTN allocation rules 
• Increase transparency for kidney patients (and their nephrologists), including retrospective sharing of organs declined on patients’ behalf with the patients and their nephrology care team 
• Expedite the CMS release of an organ procurement organization rule that addresses concerns with tiering, methodology, and plans for procurement service in communities following decertification of any organ procurement organizations
• Revise transplant center flagging thresholds for two post-transplant metrics (adult 90-day and 1-year conditional graft survival), a change that is hoped will allow programs greater flexibility in accepting kidneys that would benefit many patients but today go unused (note: this positive change was recently finalized)
• Aligning goals and incentives for OPOs with those of the transplant centers to facilitate timely, fair and transparent matching of organs to recipients
• Providing feedback to programs that declined organs regarding whether or not those organs were successfully transplanted elsewhere
• Developing and expanding use of clinical decision support tools for transplant professionals who make organ offer decisions

Recently, the society led efforts to have the Health Resources and Services Administration (HRSA) propose expansion of the Organ Procurement and Transplantation Network (OPTN) data collection to include pre-waitlist data for all solid organ transplant patients, which was released for public comment last year and which ASN robustly supported.  

In the April issue of Kidney News, Transplant Policy Committee members Rachel Patzer, PhD, MPH, president and CEO of the Regenstrief Institute in Indianapolis and a professor at Indiana University, and Sumit Mohan, MD, MPH, FASN, professor of medicine and epidemiology at Columbia University in New York, will discuss committee efforts to increase transplant access and transparency.