June 29, 2004 — Editor's Note: On June 24-25, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) Board of Directors approved a revolutionary change in organ allocation policy, known as transplant benefit, intended to balance anticipated duration of survival on the transplant list with length of benefit from receiving a transplant. Priority for transplanted lungs will go to those candidates most urgently needing a transplant and expected to receive the most survival benefit from the transplant.

Unlike earlier lung allocation policy, which assigned priority based on the amount of time candidates had awaited a transplant, the new policy considers the waiting-list urgency and transplant benefit of each candidate based on their own clinical diagnostic factors. Implementation of the new policy is planned for early 2005, to allow for programming of the computerized organ matching system and education of both transplant professionals and potential organ recipients.

To learn more about the implications of the new policy, Medscape's Laurie Barclay interviewed Joel D. Newman, assistant director of communications for UNOS.

Medscape: What was the impetus behind creating the new rules?

Mr. Newman: For years we have sought to have a lung allocation system that is more finely tuned to the needs of transplant candidates. In the last few years specifically, federal regulations have given us new guidelines for developing policy along these lines, and we have more sophisticated data to help us understand how lung transplant candidates progress. 

Medscape: How have the new rules changed from preexisting rules for lung allocation?

Mr. Newman: Previous lung allocation policy was essentially a time-based waiting list — those who had waited the longest were the first considered for organs of a matching blood type and size. The new policy uses data-derived assessments of both a candidate's likelihood of mortality without a transplant and his or her likely posttransplant survival benefit. The patients with the greatest net benefit will be those who get the highest priority.

Medscape: How do these allocation rules compare with other organ allocation rules such as those for heart and kidney?

Mr. Newman: It is probably most similar to liver allocation policy, which also has a data-driven formula to assess the likelihood of wait-list mortality. But this policy is unique in that it also considers posttransplant survival. This is currently not done with any other organ allocation policy, but it is likely to be considered as other organ-specific policies continue to evolve. 

Medscape: What are the anticipated benefits from the new rules, and are there any potential disadvantages?

Mr. Newman: The fact that the policy is evidence-based allows us to be more responsive to the needs of individual patients, and it should reduce the number of people who die on the transplant waiting list. Even so, we will not know all of its real-life effects until implemented, and we plan to assess and update the policy as needed to provide the maximum benefit for candidates.

Medscape: Which groups of potential recipients will benefit from these rules, and which groups should anticipate a longer wait or lower probability of receiving a donor organ?

Mr. Newman: Candidates will receive an individual score, which will change as their clinical factors change, so it's hard to say who might wait shorter or longer. In general, those whose current condition is relatively stable and who have a lower mortality risk might wait longer than others. But we recognize that different categories of lung disease progress at different rates, and candidates will be assessed according to one of four diagnosis groups to allow us to use the most clinically relevant factors for each person. And candidates' scores can be recalculated if their condition changes.

Medscape: Will different rules apply to adults and children?

Mr. Newman: There are not many very young children awaiting lung transplants, and they pose some unique challenges. Children age 11 years and younger will continue to receive priority based on waiting time and compatibility with donors, while any candidates 12 years or older will be prioritized according to the new policy. Because of donor size and lung capacity, small children donors will likely only be medically compatible with candidates of similar age and size.

Medscape: Why is there a delay before these rules will be implemented for lungs and applied to other organs?

Mr. Newman: We must program the matching system and notify transplant centers and candidates of the change. We will also need to begin collecting additional data on the transplant candidates prior to implementation.

Medscape: Is there anything you would like to add in closing?

Mr. Newman: While we believe this new policy is a significant improvement, we are still limited by the number of donated organs available. We hope that by demonstrating to the public that we are using these precious resources in the most responsible way, we will encourage more people to save lives through committing to organ donation.

Reviewed by Gary D. Vogin, MD