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Access for Urgent Liver Candidates in Hawaii and Puerto Rico

Proposal Overview

Status: Implemented

Sponsoring Committee: Liver and Intestinal Organ Transplantation

Strategic Goal: Provide equity in access to transplants

Policy Notice (PDF; 01/2020)

View the Briefing Paper (PDF; 01/2020) 

Read the proposal (PDF; 12/2019)

Contact: Betsy Gans

Executive Summary

For liver candidates listed in Hawaii or Puerto Rico who need a liver transplant very urgently, there may not be a donor of compatible blood type within 500 nautical miles (NM) in the time frame they need. This proposal would create additional geographic units that only apply to these candidates in order to broaden the pool of donors for whom these candidates would be likely to receive offers. For candidates in Hawaii, there would be an additional unit of distribution of 2,400 NM between the donor and transplant hospitals. For candidates in Puerto Rico, there would be an additional unit of distribution of 1,100 NM between the donor and transplant hospitals. These additional units of distribution would follow allocation classifications for candidates of similar medical urgency within 500 NM of the donor hospital.


OPTN Transplant Coordinators Committee | 01/10/2020

The Transplant Coordinators Committee strongly supports the OPTN policy proposal as written on “Access for Urgent Liver Candidates in Hawaii and Puerto Rico”. We agree that allocation changes are required in order to improve access to patients who reside in Hawaii and Puerto Rico, who may otherwise be faced with reduced access to organ offers based solely upon their place of residence. We understand this proposal as an attempt to correct an inequity that has emerged due to recipient geographic location. We appreciate that the Liver Transplantation Committee has addressed the needs of high urgency patients residing in these remote island communities. The Committee feels that while data estimates that a small volume of livers will be shared in this allocation scheme, that attention remain on identifying and evaluating potential unintended consequences that may arise from logistical challenges. Given that organs will be traveling for critically ill patients, suggestions include: • a requirement that an accepting transplant program not consider subsequent organ offers from other donors once the accepted liver has departed the fixed base operator (FBO) used by the host organ procurement organization (OPO), or • a well thought out process for how to redirect the chartered aircraft to return to FBO within a certain timeframe so that the organ could be utilized by a transplant center in the contiguous United States. • to have established a local back-up for the donated organ. The Committee recommends the following elements to consider in post-implementation monitoring: • Include number of livers offered, accepted, declined, transplanted, instances of local back-up, and instances of organs recovered and not transplanted by transplant centers in Hawaii and Puerto Rico that were allocated under the proposed new variance. The Committee appreciates the opportunity to provide feedback to the Liver & Intestine Transplantation Committee.

Society for Pediatric Liver Transplantation (SPLIT) | 01/09/2020

The Society for Pediatric Liver Transplantation (SPLIT) strongly supports policies that broaden liver allograft sharing to medically urgent candidates, including this policy. We support increasing allocation distances for vulnerable populations that await liver transplant in Puerto Rico and Hawaii. These populations are vulnerable to worsening liver disease, and when they are children, may suffer irreversible impact on their health and development as they await liver transplant. Their opportunities to access high-quality donors are limited. Vulnerable populations in all regions of the U.S. and outlying territories, should be appropriately prioritized to minimize their morbidity and mortality.

American Society of Transplantation | 01/09/2020

The American Society of Transplantation is generally supportive of the proposal as written but offers the following comments. The Society believes that it will be important for the OPTN to be transparent in showing the impact of the AC model on other mainland centers who may be disadvantaged by it. It was suggested that, based on the historical data for Puerto Rico, a cut-off distance of 1,100 NM would exclude 13 of the 23 mainland liver allografts they utilized from 2012-2017, but increasing that to 1,600 NM would allow access to allografts they have utilized under regional sharing. However, the impact of this larger distance on the mainland centers also needs to be considered.

Auxilio Mutuo Hospital | 01/08/2020

I want to thank the OPTN/UNOS for putting up this project to safeguard the sickest patients of the underserved populations of Hawaii and Puerto Rico once the 500 mile rings are in place. Over the years both regions have been net exporters of organs, roughly 50% of the organs produced. With the introduction of the Share 35 initiative, we have been able to import between one and three organs per year while exporting around 50 livers. The Region 3 helped us when maximum need existed and they benefitted as first recipients of Share 35 priority organs and of those discarded by us due to lack of recipients or unacceptable level of marginality for our resources. With this proposal, most of Florida, the closest State to Puerto Rico, distant 850 nautical miles, will provide donor livers when our patients reach 37 of MELD or Status 1. It is not clarified in the proposal which centers will benefit from our exports once the rings are in place, as we assume they would go to a National list. Our Center would support that the same area providing the donor livers for our high priority patients should benefit from our surplus.

AOPO | 01/06/2020

The Association of Organ Procurement Organizations (AOPO) appreciates the opportunity to provide comment on the proposal to provide equity in access for urgent liver candidates in Hawaii and Puerto Rico. We support the proposal as written and ask that the OPTN monitor outcomes to assure the units of distribution outlined are broad enough to meet the need of those urgent candidates waiting in non-contiguous states/territories.

NATCO | 01/06/2020

NATCO strongly supports the proposal to create a variance for Hawaii and Puerto Rico which adds additional distance to the distribution for livers for medically urgent candidates in these locations. As with other recommendations, we continue to recommend the implementation of regular assessments to identify any potential unintended consequences that may arise due to logistical issues, or unintended consequences to pediatric patients on the wait list.

Starzl Network for Excellence in Pediatric Transplantation | 01/06/2020

The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) strongly supports policies that broaden liver allograft sharing to medically urgent candidates and agrees with appropriately increasing allocation distances for sick children awaiting liver transplant in the geographically remote islands of Puerto Rico and Hawaii.

American Society of Transplant Surgeons (ASTS) | 12/30/2019

The American Society of Transplant Surgeons (ASTS) strongly supports the OPTN policy proposal as written on “Access for Urgent Liver Candidates in Hawaii and Puerto Rico.” ASTS thanks the OPTN Liver Transplantation Committee for addressing the needs of “high urgency” or status one candidates in these island communities and for aligning this proposal with proposed allocation policy removing DSAs and Regions from the process. The data shows this policy will have very minimal impact on the regions designated to share including Washington, Oregon, and California for candidates in Hawaii and most of Florida for candidates in Puerto Rico. We note there have been as little as approximately 2 livers needed for recipients in Hawaii and roughly 5 for recipients in Puerto Rico per year. We recommend the OPTN take an iterative approach to all new organ allocation policies by taking small steps with regular reassessments (e.g., one year, etc.) to identify successes and unintended consequences, particularly concerning logistical issues.

Anonymous | 12/20/2019

While I hope the development of other sources continues toward actual usability ("grown", for example), it is imperative we include the "remote" parts of the US in the process available to other members of the US now. There are several changes needed in our "system", this one is key. I would hope our goal is to provide equitable services. At least this approaches "fair".