Comments

Transplant Families | 10/03/2025

Transplant Families supports this proposal and echoes the reasoning cited by Dr. Amaral, the OPTN Pediatric Committee, and Rady Children’s Hospital.

A comprehensive and standardized multi-organ allocation framework is critical to ensuring that equity is preserved for the most vulnerable patient groups, especially pediatric candidates, medically urgent patients, and highly sensitized individuals. The current patchwork approach to multi-organ allocation often disadvantages children and single-organ candidates, who may lose access to life-saving transplants under inconsistent practices.

We recognize that multi-organ allocation is complex, but that is precisely why a national, standardized approach is needed. We strongly support the adoption of this proposal and encourage robust monitoring and training to ensure its successful implementation.

Infinite Legacy | 10/01/2025

Infinite Legacy supports the proposed changes to the multi-organ allocation system and is pleased to provide the following comments and recommendations for this policy. We applaud the Multi-Organ Transplantation Committee for their work to provide OPOs with guidance that will enable enhanced precision, equitable access, and greater transparency in multi-organ allocation. Improving multi-organ allocation algorithms will also allow OPOs to better streamline organ placement efforts. Ultimately, a standardized framework for multi-organ allocation is a critical aspect of creating and maintaining a more consistent and fair system nationwide.

The proposed changes will help stakeholders ensure that every donated organ is used to its fullest potential with the flexibility needed for unique donor situations and single-organ transplants. While these changes represent important progress towards more efficient and equitable access to transplant, we recognize that this policy may result in some negative impact on kidney-pancreas recipients as well as kidney-alone pediatric recipients. As outlined in greater detail below, we recommend proceeding with policy implementation thoughtfully, with a particular focus on education and training, ongoing monitoring, and transparent reporting of allocation data.

We urge the OPTN to incorporate equity-focused metrics that assess whether kidney-alone candidates, especially pediatric and minority patients, are receiving fair access under the new framework. We also highlight the importance of leveraging community-driven initiatives like The Decision Project to help shape education, training, and monitoring efforts, ensuring the system is understood and trusted at the neighborhood level. When implementing the policy, we recommend that the OPTN publish transparent allocation data that can be used by both medical and community stakeholders to evaluate whether reforms are achieving the intended improvements in equity and trust.

Region 2 | 10/01/2025

Sentiment: 5 strongly support, 4 support, 3 neutral/abstain, 1 oppose, 1 strongly oppose

Comments: Several attendees emphasized that at least one kidney from each low KDPI donor should primarily go to a kidney-alone or kidney-pancreas candidate, noting that simultaneous pancreas-kidney (SPK) recipients are fundamentally part of the kidney transplant population. Concerns were raised that placing the highest quality kidneys into multi-organ recipients—where grafts fail more frequently—could reduce access for kidney-alone candidates who might derive the most long-term benefit. This was linked to a higher rate of primary non-function in kidney grafts for multi-organ groups, which could drive earlier graft failure and increased need for repeat transplants. Attendees noted the importance of monitoring pancreas utilization closely, given ongoing challenges and high non-use rates. Specific concerns were expressed about highly sensitized SPK candidates potentially losing access to SPK transplants under the proposed allocation tables, with requests that the pancreas follow the kidney in such cases, or that allocation tables prioritize high CPRA, 0-mismatch, pediatric, and prior living donor candidates for kidney-alone first, followed by SPK, and then other multi-organ candidates. Several emphasized the need to review the CPRA point scale in light of the new 250 nautical mile allocation circles, as the current system was designed before this change and may no longer reflect the appropriate balance between highly sensitized and unsensitized candidates. While some attendees affirmed that multi-organ recipients need continued access, others stressed the need for clear, uniform national guidance so that OPOs are not making inconsistent decisions. Attendees noted that allocation is already highly complex in multi-visceral cases involving heart and lungs, and adding kidney-pancreas or other combinations will increase this complexity. They recommended programming algorithms into the OPTN Computer System to reduce opportunities for error or deviation. Equity concerns were also raised, particularly by a rural transplant program that noted its kidney candidates already face systemic barriers to access, making clarity and fairness in allocation policy especially important. Several attendees agreed that the policy title should be revised to reflect the scope of the changes, and that future policy adjustments will be necessary once data are available to evaluate outcomes. A final point highlighted the need for improved system knowledge and functionality around how allocation proceeds when a multi-organ candidate appears on a match run, as the current system does not adequately support this.

Region 1 | 10/01/2025

Sentiment: 2 strongly support, 8 support, 1 neutral/abstain, 0 oppose, 0 strongly oppose

Comments: An attendee was impressed, noting that this is essentially continuous distribution for multiorgan and that the median appearance table helps clarify the structure. A member acknowledged the significant effort behind the proposal and raised the issue of prioritizing first versus subsequent transplants, questioning the ethics of bypassing a sick liver patient for someone with multiple prior transplants. An attendee appreciated the committee’s work and noted that the need for this policy was identified in 2019. A member suggested that this would be better integrated with continuous distribution and should be part of discussions on allocation out of sequence. An attendee expressed concern that requiring a plan could hinder expedited recoveries of hearts, lungs, and livers due to delays in receiving kidney HLAs, and noted that machine perfusion scenarios should not be considered violations of multi-organ allocation policies. A member supported the proposal with conditions, including transparent logic, exception tracking, and regional simulations before rollout. An attendee acknowledged the complexity of the policy and encouraged continued effort.

University of California San Diego Medical Center | 10/01/2025

I support this. I propose that the highest organ severity index lead the organ allocation. For example for a heart lung transplant, candidate with a high CAS (eg 36) and a status 3 heart will have to wait until the heart run goes through first before the candidate can obtain the combined organ. I am in agreement with the proposed changes particularly with a 3 lung CIS threshold depending on whether the donor is blood type O.

Luis Mayen | 10/01/2025

As someone who has worked in organ donation and transplantation for over 20 years, I've experienced the challenges that arise from balancing equity and efficiency in allocation without a specific multi-organ allocation policy. The need for a clear and comprehensive framework has long been evident, and I strongly support the effort to standardize this process.

I offer this comment also as an altruistic living donor, a perspective that reinforces for me the importance of ensuring that our policies are transparent, fair, and sustainable. Multi-organ candidates deserve clear rules that respect their medical urgency, while single-organ candidates—particularly children—must also be assured a fair opportunity to receive the gift of life.

Pediatric patients are uniquely disadvantaged when allocation lacks structure or consistency. They have fewer potential matches, limited time, and an entire lifetime at stake. Any comprehensive multi-organ allocation policy should explicitly safeguard pediatric priority so that children are not overlooked in situations where multi-organ candidates may otherwise draw a disproportionate share of offers.

I also encourage the OPTN to consider whether current policies go far enough in protecting living donors who later find themselves in need of a transplant. While kidney donors do receive meaningful allocation priority, protections for living donors of other organs are not as clear or consistent. Our system should extend stronger and more uniform protections across all organ types, honoring the extraordinary gift these individuals have made and ensuring that they are not left vulnerable should they one day need a transplant themselves.

Steven Potter | 10/01/2025

This proposal, as structured, will significantly impair access to organs for Kidney-Pancreas candidates.

By moving Kidney alone for Peds candidates above KP classification 4, we will likely increase the discards of good quality pancreata. That will likely occur because once the procurement is completed and a pediatric program then turns down the kidney(s) from that donor, bringing those kidneys back into the allocation cycle, the pancreas will already be gone.
In the current system, organ wastage is prevented in this scenario because an intraoperative or late turndown of a pancreas (typically because it is found unsuitable for transplant at OR visualization or due to anatomic/vascular defect or anomaly), the kidneys have no CIT and are efficiently utilized.

That is, in my estimation, the biggest problem with this proposal. As detailed in Table 5 of the OPTN proposal document (Table 5: MOT Committee's recommended placement..."), Kidney classification 6 is above virtually all the KP candidates (the median appearance number in the first three K/P classifications are all ZERO). Thus, placing the Kidney-alone classification below K/P classifications 1-3 is not functionally helpful for K/P, as those K/P classifications contain such small numbers of candidates. Almost all of the K/P candidates are transplanted in K/P Classification 4 currently, and placing Kidney-alone Classification 6 above those K/P candidates will dramatically impair access to this population which faces dramatic mortality risks while wait-listed.

This proposal will seriously impair access for pancreas and will significantly impair pancreas transplant programs and endanger the patients they serve.

American Society of Transplant Surgeons | 10/01/2025

Please see attachment.

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Rady Children's Hospital and Health Center | 10/01/2025

On behalf of Rady Children’s Hospital, we appreciate the opportunity to provide feedback on this developing policy to standardize multi-organ placement.
As a local pediatric transplant center surrounded by three large, higher-volume KP programs, our single-organ kidney pediatric patients are routinely surpassed by KP candidates within our 250 NM area. We have significant concern about the current proposal for kidney allocation: the current proposal places our pediatric patients, a vulnerable population, at a disadvantage by limiting their access to life-saving kidneys, negatively impacting their development and compounding long-term health risks.
In considering the newly proposed allocation table (DBD donors age 18-69, KDPI 0-34%), national KP's with a PRA of >80 % are placed above pediatric kidneys, medically urgent kidneys, and kidney alone recipients with a PRA of 98%. Despite clearly better outcomes for pediatric kidney transplant compared to KPs and pancreas alone, this algorithm unfairly benefits KP patients over our pediatric patients and more urgent or difficult to transplant adult kidney recipients.
It is detrimental to our pediatric population to carry on with this proposed allocation. Sending organs nationally, including kidneys that go with a pancreas graft, increases the potential for non-use or out of sequence allocation. In addition, placing KP's within 250 nm over the pediatric population is a long-standing barrier to transplant for our pediatric recipients that exacerbates existing disparities. KPs are frequently placed ahead of time to the procurement, declined intraoperatively, and then logistically challenging to transplant last minute in a child.
We cannot overstate the long-term harm dialysis inflicts on children. In addition to a substantially increased risk of mortality as compared to timely transplantation, every additional month on dialysis affects not only their growth and development but also their families’ well-being. In our experience, the length of time a child spends on dialysis directly determines how well they can return to a “normal” life after transplant. Many complications caused by prolonged dialysis never resolve, leaving children with lifelong conditions rooted in renal failure during their formative years. By deprioritizing pediatric kidney transplant patients with this allocation policy, we are minimizing the survival advantage and increasing the long-term health risk for this population. Without adjustment, this policy risks compounding health disparities for children who already face unique vulnerabilities.
Our proposal is to place pediatric kidney recipients, recipients with higher CPRA and medically urgent kidney alone recipients above national placement of KPs and KPs within 250nm. This will provide the best access and equity to the most at-risk transplant recipients who have the most to gain from timely transplant.

American Society of Nephrology | 10/01/2025

Please reference attachment.

View attachment from American Society of Nephrology

Region 4 | 10/01/2025

Sentiment: 2 strongly support, 16 support, 2 neutral/abstain, 3 oppose, 0 strongly oppose

Comments: During the discussion, several attendees expressed concerns regarding the placement of pediatric kidney candidates in the proposed multi-organ allocation system, particularly for DBD donors aged 18–69 with KDPI 0–34, which represents most pediatric kidney donors. They noted that pediatric candidates remain at a significant disadvantage compared with adult kidney/pancreas candidates and emphasized that post-implementation monitoring will be essential to ensure fairness for single-organ candidates, especially pediatric and pancreas patients. One attendee commented that the proposal does not fully account for the complexities of multi-organ transplantation, particularly heart-liver and heart-kidney combinations, which are becoming more common in certain populations. They recommended that the committee reassess prioritization either prior to implementation or shortly after, to limit eligibility for kidneys with secondary organs. They also recommended giving higher priority to previous living donors. Additionally, they commented that it would be beneficial to allow centers to see where their candidates are prioritized within the multi-organ plan. Another attendee recommended that transplant centers have access to the seven allocation tables, and one called for a transparent data analysis of the policy’s impact, particularly on pediatric allocation. They also requested additional education on heart-liver multiorgan transplants, which are becoming more common than heart-kidney transplants in their population, especially regarding Status 3 adult and Status 1A pediatric heart candidates. Another attendee commented that there is a need for standardized processes across OPOs. They also raised concern about potential disadvantages for kidney/pancreas recipients under the new system. Attendees also noted that while the new system-generated plan represents an improvement, challenges remain in handling late declines, rapid cases, and media scrutiny surrounding allocation decisions. One attendee commented that continuous distribution may allow better comparison across organs, but current policy often prioritizes multi-organ recipients at the expense of maximizing the benefit to multiple single-organ recipients. One attendee commented on the specific disadvantages to pediatric kidney recipients, adding that the left kidney is often allocated to multi-organ recipients, leaving high-risk options or no offers for pediatric recipients. Attendees recommended careful post-implementation monitoring and ongoing work to adjust allocation policies to ensure equity and optimize outcomes for both pediatric and adult single-organ recipients. One attendee commented that there aree operational challenges with the policy including how the system handles late declines, rapid cases, and the growing scrutiny from media and external groups around Allocation Outside of System (AOOS) decisions. They added that while the system-generated plan is an improvement, they are concerned that the punitive tone surrounding AOOS could lead to increased scrutiny from HRSA, CMS, and OPTN. The need for standardized processes across OPOs was also raised to ensure consistency and fairness. One attendee noted that the current allocation system does not fully account for the broader impact of multi-organ transplants, which provide multiple organs to a single recipient rather than maximizing benefit across multiple single-organ recipients. They added that it is difficult to do this within the current allocation system, but continuous distribution may enable better comparison across organs.

Association of Organ Procurement Organizations (AOPO) | 10/01/2025

AOPO supports the establishment of a Comprehensive Multi-Organ Allocation Policy. Allocation represents one of the three pillars of the work undertaken by OPOs, along with policies related to authorization and the determination of organ suitability. Clear and consistent allocation policies, developed in alignment with congressionally established mandates, enable OPOs to fulfill their responsibility: to recover transplantable organs and ensure those life-saving organs reach patients whose futures depend on a well-functioning donation and transplantation system.

The proposed Comprehensive Multi-Organ Allocation Policy brings needed uniformity to the allocation and prioritization of organs from donors who are able to donate multiple life-saving organs. It strengthens trust in the system by providing a consistent and predictable allocation process to transplant candidates by organ and listing status. Enhancements to the electronic systems that manage the multiple lists generated under the policy will improve coordination across transplant centers and OPOs, ensuring the efficient recovery, timely placement, and transportation of donated organs to the right patients.

Importantly, the proposed policy spotlights the special concern for single-organ candidates, such as pediatric, medically urgent, and highly sensitized candidates. These patients who need a transplant, along with all others – and their families –will directly benefit from the safeguards and consistency this policy introduces.

AOPO welcomes the opportunity to collaborate with our partners in the donation and transplant community to develop advance training on the new policy, support a smooth transition for all participants, and monitor its effectiveness once implemented.

Mid-America Transplant | 10/01/2025

Mid-America Transplant (MOMA) appreciates the opportunity to provide feedback to the OPTN regarding its proposal to Establish a Comprehensive Multi-Organ Allocation Policy .

MOMA appreciates the OPTN Multi-Organ Transplantation Committee’s efforts to bring clarity and consistency to multi-organ allocation. The proposed policy’s use of standardized allocation tables and a system-generated donor-specific plan represents meaningful progress toward equitable and transparent organ distribution.

MOMA has concerns around the practical feasibility of implementing this policy in its current form. The requirement to generate a unique multi-organ allocation plan for each donor introduces significant complexity. With seven different allocation tables and a binary “must/must not” framework, coordinators must interpret and manually apply intricate rules for each case. This manual process increases the risk of unintentional errors, inefficiencies, and potential non-compliance, especially in high-pressure, time-sensitive environments.

To mitigate these risks, MOMA recommends that multi-organ allocation be automated to the greatest extent possible. Specifically, we urge OPTN to integrate the multi-organ allocation rules directly into DonorNet match runs. This would allow the system to automatically reflect the correct priority and organ combinations, reducing reliance on manual interpretation and improving consistency across OPOs.

We support the policy’s goals and believe that automation is essential to achieving them effectively. We encourage OPTN to prioritize system enhancements that encode allocation logic into the match runs themselves, ensuring that the policy is not only clear but also operationally sustainable.

OPTN Membership & Professional Standards Committee | 10/01/2025

The Membership and Professional Standards Committee (MPSC) appreciates the diligent work of the Ad Hoc Multi-Organ Transplantation (MOT) Committee in developing these allocation policy changes and presenting them to the MPSC. Overall, the MPSC supports the proposed changes and offers the following comments and recommendations for consideration.

An MPSC member began the discussion by acknowledging the challenges faced by highly sensitized single-organ candidates, particularly those with 100% calculated panel reactive antibody (CPRA), and expressed support for the proposed changes aimed at improving their access. The member emphasized the importance of entering human leukocyte antigen (HLA) typing prior to executing match runs to prevent organ offers to candidates with unacceptable antigens who were not filtered out, thereby improving allocation efficiency. This practice was noted to be increasingly important for thoracic organ candidates, with a possible exception for liver match runs. Another member noted that in some cases, HLA typing may not be available until after organ recovery, however allocation for extra-renal organs may need to occur prior to recovery. In recognition of this, the member suggested that exceptions may be necessary, so additional clarity about these scenarios is desirable.

There were concerns raised about the static nature of the allocation plan, particularly for organ match runs that are executed after the allocation plan. Because the allocation plan does not include organs that do not have a match run at the time the plan is executed, members request clarity about the appropriate procedure for the possibility that the OPO later decide to allocate those organs. The MPSC member advocated for transplant centers to have visibility into the organ placement logic to promote transparency in the allocation process in these scenarios of changing circumstances. It was also suggested that the MOT committee consider a three-to-six-month implementation grace period before beginning to evaluate member compliance, due to concerns about operational challenges, unintended consequences, and the need for a substantial learning period given the complexity of the proposed changes.

Several MPSC members discussed the importance of increasing priority for pediatric kidney candidates and adult candidates with low Estimated Post-Transplant Survival (EPTS) scores in the multi-organ allocation tables, alongside highly sensitized and prior donor groups. Members urged the MOT Committee to elevate pediatric priority due to their vulnerability and developmental needs. It was also noted that adult candidates with low EPTS scores, who tend to be younger, have demonstrated better graft longevity when receiving kidneys with low KPDI scores. Given that dialysis carries its own risks, these candidates should be considered for increased priority to help maximize the gift of these organs. 

The Chair asked about what considerations had been made regarding compliance and allocation out of sequence (AOOS) when utilizing the proposed multi-organ allocation plans. It was discussed that the proposed tables and system generated allocation plan would provide clear metrics for compliance with the proposed policy, and the Chair noted some concern that the proposal could potentially put members at risk for non-compliance with multiple policies for a single instance of AOOS. A member suggested using a pop-up warning feature if an allocation was going to be AOOS or outside of the multi-organ allocation table. Another member asked about candidates that do not appear on the multi-organ allocation plan, and it was clarified that it will still be permissible to allocate multi-organ combinations once the allocation plan has been completed, ensuring that other candidate groups continue to receive offers. An additional member observed lung candidates whose CAS scores don’t place them on the allocation plan and it was noted that the lung committee was asked for their recommendations for scores thresholds suitable for the allocation plan and that the remaining lung CAS scores would be allocated from the lung match run. 

The MPSC is grateful for the MOT Committee’s extensive work on this proposal and appreciates their thoughtful consideration of the committee’s feedback.

OPTN Pediatric Transplantation Committee | 10/01/2025

The OPTN Pediatric Transplantation Committee (Pediatric Committee) thanks the OPTN Multi-Organ Transplantation Committee for its work on this proposal. While the consideration of past feedback and additional data on median appearances is appreciated, the Pediatric Committee carries forward concerns about pediatric priority in proposed donor allocation tables.

The Pediatric Committee generally supports:

• Standardizing the process for multi-organ allocation
• Improving priority for kidney-alone candidates with 100% CPRA
• Prioritizing pediatric kidney-alone candidates before Pancreas or K/P Classifications 1-4 for DBD donors aged 11-17 with KDPI of 0-34%
• Prioritizing pediatric kidney-alone candidates before Pancreas or K/P Classification 4 for DBD donors aged <11 with KDPI of 0-34%

However, we anticipate little overall benefit for pediatric kidney-alone candidates. Kidney donors aged <11 with KDPI of 0-34%, especially those 7 and under, are typically not ideal due to their smaller size. The most appropriate offers would be from teenage and adult donors.

We strongly advocate for pediatric kidney-alone priority before Pancreas and K/P classifications in donor allocation tables, particularly in the table for donors aged 18-69 with KDPI 0-34%. Median appearance data shows only 3 pediatric kidney-alone candidates typically appear on match runs, while 27 Pancreas and K/P candidates typically appear. Theoretically, this small number of pediatric kidney-alone candidates should not significantly impact Pancreas and K/P allocation. Whereas, Pancreas and K/P priority before pediatric priority may pose a risk for missed pediatric transplant opportunities, given the frequency of late declines among K/P candidates.

Additionally, significant concerns remain for highly sensitized pediatric kidney candidates with CPRA <100% as priority for these candidates may not improve until Continuous Distribution of Kidneys moves forward.

OPTN Patient Affairs Committee | 10/01/2025

The Patient Affairs Committee (PAC) supports the goals of the Multi-Organ Transplant (MOT) proposal and continues to advocate for increased fairness and transparency in the organ allocation system. It is crucial that significant changes in allocation policies are explained clearly in real-world terms. It should be evident for both single-organ and multi-organ candidates on the waitlist what this type of change will mean for them. Additionally, the PAC recommends that the proposal more clearly address how the OPTN will ensure compliance by OPOs and align with the Board’s ongoing AOOS efforts. Finally, the Committee requests clarity on the timeline for implementing these changes and how they will be incorporated into broader OPTN system modernization plans.

Lenore Hicks | 10/01/2025

I would like to thank the committee for all of its hard work; this was not an easy task. I am very much in favor of the standardization of allocation among the OPOs. In the data that was collected, was there any data on discards, and if so, what was the cause? What data and for how long to determine if this is a success? How will the public and recipients be informed of these new changes? I am not sure of what the binary offer for a must/must not offer is.

Donor Network West | 09/30/2025

As the federally designated Organ Procurement Organization (OPO) serving Northern California and Nevada, Donor Network West supports the Ad Hoc Multi-Organ Transplantation Committee's initiative to establish a Comprehensive Multi-Organ Allocation Policy.

Key Points of Support:

Alignment with the OPTN Final Rule: We commend the Committee's efforts to ensure that the proposed policy aligns with the OPTN Final Rule and the transition to a continuous distribution framework.

Data-Driven Decision Making: Standardized allocation tables are a positive step toward data-informed policy development. We support the Committee's approach to ground allocation decisions on empirical data to optimize organ utilization.

Consideration of Match Re-Executions: We appreciate the Committee's discussion on the potential requirements and processes for rerunning matches and multi-organ allocation tables. Implementing such measures can enhance the fairness and efficiency of the allocation process.

Recommendations:

Enhanced Stakeholder Engagement: We encourage the Committee to continue engaging with a diverse range of stakeholders, including patient advocacy groups, transplant centers, and OPOs, to ensure that the policy reflects the needs and perspectives of all parties involved.

Monitoring and Evaluation: We recommend establishing mechanisms for ongoing monitoring and evaluation of the policy's impact to identify areas for improvement and ensure that the policy achieves its intended outcomes.

Donor Network West looks forward to collaborating with the Committee and other stakeholders to implement a policy that enhances the equity and efficiency of the organ allocation system.

NATCO | 09/30/2025

On behalf of the NATCO, we appreciate the opportunity to comment on the proposed multi-organ allocation policy.

NATCO supports this proposal because it advances equity, transparency, and consistency in allocation. We commend the effort to:

1. Standardize allocation across match runs, reducing variability and discretionary decision-making.

2. Improve access for high-priority single-organ candidates, including pediatric, highly sensitized, and medically urgent patients.

3. Implement a clear must/must not framework for multi-organ offers, replacing subjective “permissible” options.

4. Provide system-generated, donor-specific allocation plans to guide OPOs step by step.

Must-haves for successful implementation:

1. Strong IT system support with intuitive guidance, alerts, and navigational aids.

2. Robust pre-implementation training for OPO and transplant staff.

3. Rigorous post-implementation monitoring of equity impacts, pediatric outcomes, and organ non-use.

4. Transparent modeling and data to prepare centers for operational changes.

We recognize that complexity will increase with multiple donor categories and allocation tables, but believe the policy will ultimately be easier to follow than current practice once supported by system tools and training.

In summary, NATCO supports the adoption of this proposal and urges the OPTN Board to ensure proper system upgrades, education, and monitoring to realize its full benefits.

Joseph Hillenburg | 09/30/2025

This policy is a good first step, but I agree with the comments by Dr. Amaral and request that pediatric allocation should be prioritized.

I also ask that the committee consider with caution comments citing questionable sources such as Washington Post.

OPTN Operations and Safety Committee | 09/30/2025

The OPTN Operations and Safety Committee thanks the Multi-Organ Transplantation (MOT) Committee for their efforts on the Establish a Comprehensive Multi-Organ Allocation Policy 2025 proposal and the opportunity to comment. The Committee provides the following feedback:

Accessibility of information for transplant programs: The Committee asks for consideration in allowing transplant programs the ability to see this information either at the start of allocation or prior to offers going out to better understand why their potential transplant recipient (PTR) is not offered the organ. This information would be helpful for transplant programs to understand their PTRs’ relative priority on the match, especially during later hours of the night.

HLA typing: The Committee voiced strong concern to the requirement of HLA typing being entered prior to generation of the multi-organ allocation plan. While it is ideal for allocation to proceed with HLA typing entered, the Committee emphasizes the need to consider scenarios involving kidney-only or rush cases. Specifically, there are instances where the organ procurement organization (OPO) may be allocating kidneys only and could face unnecessary delays if needing to wait for HLA entry prior to allocation. The Committee strongly recommends consideration for the establishment of a compliant pathway that permits allocation for kidney-only offers or rush/urgent cases.

The Association for Multicultural Affairs in Transplantation | 09/30/2025

Please reference attachment.

View attachment from The Association for Multicultural Affairs in Transplantation

American Society of Transplantation | 09/30/2025

The American Society of Transplantation (AST) offers the following comments in response to the proposal, “Establish Comprehensive Multi-Organ Allocation Policy.” The AST strongly supports the goal of standardizing multi-organ allocation. Efforts to standardize multi-organ allocation across the transplant system are needed to balance equity and efficiency when allocating organs; however, the AST has some concerns with the approach and policy changes outlined in this proposal.

The AST is concerned that kidney alone and kidney-pancreas (KP) candidates, including pediatric kidney candidates, may be disadvantaged by this proposal. Preferential allocation of high-quality kidneys to multi-organ candidates may result in allocation of kidneys to candidates with potential for renal recovery (low net utility); this might be mitigated by more stringent requirements regarding renal function at the time of organ offer (i.e. lower eGFR) and demonstrate continued need for kidney transplantation closer to the time of organ offer. Similarly, allocation of high-quality kidneys to multi-organ candidates may result in lower graft survival (lower net utility) from these organs compared to allocation to kidney-alone candidates; this could be mitigated with policy requirements that monitor kidney transplant outcomes after multi-organ transplant to promote responsible candidate selection for multi-organ transplantation.

KP candidates differ from other multi-organ transplant candidates in that the primary organ is usually the kidney, and pancreas-alone transplant is rarely performed. A policy that reduces priority for KP candidates relative to other multi-organ candidates may result in longer wait times for KP candidates, progression of underlying diabetes and kidney related disease, dialysis access complications, and removal from the waiting list for pancreas and kidney-alone transplant. Missed opportunities to capture the benefits of pancreas transplantation for these patients threaten net utility and justice. Kidney and KP candidates face long wait times for transplantation, and although dialysis may be an option, with it comes significant personal, community, and healthcare burdens. These burdens are magnified for already marginalized candidates, candidates with social/financial stressors, and candidates with a low probability of finding a suitable organ donor. Any policy which potentially lowers priority for these candidates or allows them to be passed over in favor of other candidates for whom kidney transplantation is not the primary need is a threat to justice/fairness for these populations. Additionally, pancreas utilization is highest when the pancreas goes with the kidney. The AST is concerned that highly sensitized KP candidates will not have sufficient access to a KP, only the kidney alone, based on the proposed allocation changes. A possible adjustment to explore would be to start the allocation with the high CPRA, zero-antigen mismatches, pediatric, or prior living donors for kidney alone, followed by KP, and then make multi-organ allocation offers.

The AST also recommends that pediatric kidney candidates should be prioritized before pancreas and KP classifications in the proposed allocation tables for 11-17 years old donation after brain death (DBD) donors with a kidney donor profile index (KDPI) 0-34% and DBD donors aged
Regarding pediatric liver-kidney transplants, the AST is concerned that the kidney would not be automatically allocated with the liver to these patients. Children have naïve immune systems and form donor specific antibodies (DSA) at a much higher rate than adults. One of the benefits of allocating the liver with the kidney from the same donor to children is that the liver will absorb some of the DSA allowing the kidney to last longer.

The AST recommends that at least one kidney from each donor should be allocated to a kidney alone or KP candidate. Currently, only high-CPRA (100%), zero-antigen mismatched, pediatric, or prior living donors are given any priority from these multi-organ donors.

Additionally, appropriate education regarding this policy change should be shared broadly with the transplant community. More attention needs to be provided for how OPOs and transplant centers are to handle rapid donor cases where time is extremely limited for pre-recovery allocation planning. Additional clarity on how allocation should proceed in response to intra-operative declines or necessary reallocations would also be beneficial. E.g., if heart-kidney is allocated to a potential transplant recipient, the other organs have also been allocated, and the heart is ultimately deemed unsuitable for transplant- what is the expectation for reallocating the kidney?

Finally, it is crucial that the OPTN closely monitor the impacts of these changes as outlined in the proposal. The AST suggests that the OPTN consider a defined time frame to return to these policy changes with a plan to address any concerning trends observed during post-implementation monitoring and respond with additional changes in policy. Prospectively defined parameters for pausing or adjusting the proposed policies would help to promote transparency and trust from observers concerned about threats to net utility and justice. The AST recommends that the OPTN consider monitoring the following in addition to what is outlined in the proposal:
• Monitor pancreas non-utilization from these multi-organ donors. It should be very low (or close to zero) - at minimum no higher than current rate from similar donors. Also monitor how many potential KP offers became pancreas transplant alone offers due to multi-organ allocation.

• Monitor kidney function and kidney graft survival long-term in multi-organ recipients. If kidney function at 3-months, 12-months, and 2- and 3-years is inferior to kidney alone and/or KP recipients, consider allocations changes to maximize utilization and benefit.

• Monitor utilization of safety net listing for kidney after heart, lung, or liver transplant. This should increase, not decrease over time. If it decreases, it could be inferred that these patients are receiving undue priority as compared to kidney and KP patients.

• For every multi-organ donor where a kidney alone or KP candidate did not get top priority to the kidney, monitor the outcome of this candidate. How long from the ‘multi-organ transplant miss' to when they are transplanted? What was the difference in KDPI between multi-organ transplant miss and actual transplant? One possible solution to consider is adopting policy that prohibits a kidney alone or KP candidate from being bypassed more than once due to prioritization of multi-organ potential transplant recipients.

• Monitor the re-transplant rate for kidney after heart-kidney, heart-lung, and heart-liver transplants. For this proposal to meet its goals, the multi-organ survival of patients and grafts should be equivalent or better for multi-organ than single kidney. If it turns out that multi-organ kidneys fail early and require another transplant, this would further exacerbate moving kidneys alone away from pure end stage renal diseased candidates. If this is the case, these changes will yield lost organs, life-years, and patients.

• The OPTN should pursue the development of models that include the outcomes of multi-organ recipients in the ongoing evaluation of transplant program performance.

OPTN Kidney Transplantation Committee | 09/30/2025

The OPTN Kidney Transplantation Committee thanks the OPTN Multi-Organ Transplantation Committee for their work on this proposal and the opportunity to provide input.

One member expressed concern for the volume of low KDPI donors where both kidneys are allocated to multi-organ recipients, and recommended that at least one kidney from each donor be allocated only to kidney-alone potential recipients. The member noted multi-organ candidates may have shorter post-transplant outcomes, particularly compared to pediatric kidney alone candidates. Another member remarked that it is arbitrary to retain one kidney from each donor, and instead offered that the allocation tables could be updated to increase priority for high CPRA kidney alone candidates.

One member expressed concern that it is unfair to prioritize 100% CPRA candidates with long waiting times behind multi-organ candidates. A member expressed support for considering 100% CPRA Kidney-Pancreas candidates with similar priority to 100% Kidney-alone candidates, noting this is a small but significant population. It was noted this is outside of the scope of the current proposal.

One member expressed concern for over-use of extra-renal multi-organ transplant when the patient may be more appropriately listed for a safety net kidney. The member explained that there are liver-kidney and heart-kidney candidates that are more likely to experience renal graft loss in the first year than a kidney-alone candidate, and that this graft loss could be avoided. The Committee recommends re-evaluation of the current multi-organ eligibility and safety net policies, noting this may be outside of the scope of the current proposal.

The Committee recommended providing more clarity on how offers to non-eligible simultaneous liver kidney, simultaneous lung kidney, and simultaneous heart kidney candidates will work. The Committee considered whether it is appropriate to allow candidates to be registered to the kidney waitlist without meeting relevant qualifying criteria, and noted addressing this would be a better solution to address non-eligible multi-organ candidates appearing on the match run.

The Committee considered how choice of laterality should be determined, noting instances where one patient may require a specific laterality, but does not have choice. The Committee considered anatomical considerations of transplanting young pediatric patients with limited artery space.

Global Liver Institute | 09/30/2025

Global Liver Institute supports the principle of a standardized and streamlined multi-organ allocation process as a first step toward a fair and equitable system. However, close monitoring will be critical to ensure that the policy does not inadvertently disadvantage patients in certain geographic areas.

Past policy changes, such as the 2020 “acuity circles” liver allocation policy, demonstrate the potential for unintended consequences. Analysis by The Washington Post found that patients in under-resourced states, including Alabama, Louisiana, Kansas, and North Carolina, experienced sharp declines in liver transplants, while patients in wealthier states saw gains. This geographic disparity highlights that well-intentioned allocation changes can unintentionally penalize already vulnerable populations.

We urge OPTN to implement this policy with ongoing monitoring and reporting to identify any groups or regions disproportionately affected. Safeguards should be in place to adjust allocation practices if disparities emerge, ensuring that all patients, from infants to multi-organ candidates, have equitable access to transplantation regardless of geography or other demographics.

Region 9 | 09/30/2025

Sentiment: 2 strongly support, 6 support, 0 neutral/abstain, 0 oppose, 0 strongly oppose

Comments: A member expressed support for the proposal but noted that late declines of organs may still pose challenges. An attendee felt that the initial example presented at the beginning of the session represents an unmet need. A member asked whether stratifying highly sensitized patients above multiorgan candidates has been considered, given that all organs now have safety net access. An attendee highlighted a significant gap in patient education, noting that many patients feel overlooked due to misunderstandings about the allocation system and multi-organ listings, and emphasized the need for improved communication tools and standardized processes. A member requested data on how many highly sensitized candidates have had organs transplanted above them on match runs, suggesting that this revision could improve access for PRA 100% patients. An attendee expressed interest in a pediatric proposal that prioritizes multi-organ transplants, particularly heart-liver combinations. A member stated that regulation helps ensure the right decisions are made.

Jen Benson | 09/30/2025

There is still a real gap in education for patients waiting on the transplant list. Many feel they’ve been “overlooked” or “skipped,” when in reality, much of this comes down to the allocation system and the complexities of multi-organ listings. Patients aren’t forgotten—it’s often about how the matching and allocation process works behind the scenes.

I believe this is an education issue. Whether it’s through transplant centers, videos during the listing process, or better communication tools, we need to help patients & families understand how organ offers are made. This could lessen the frustration and disappointment when the offer they’re waiting for doesn’t come. A standardized process for multi-organ allocation may help, but ultimately, stronger patient education across the board is essential.

Ronald Parsons | 09/29/2025

I applaud the MOT Committee for its work to clarify priority for high-quality kidney donors. After the Winter public comment, the committee noted “divergence on appropriate placement of kidney-pancreas and pediatric kidney classifications.” I would like to offer specific guidance.

Kidney-pancreas (KP) candidates are a distinct population. They are fundamentally kidney patients who also require a pancreas, unlike liver-kidney or heart-kidney candidates. Pancreas transplantation demands the highest-quality donors because the organ is uniquely sensitive to ischemia and comorbidities. Donors suitable for pancreas transplants are rare, yet essential for this population. Without intentional priority, many SPK candidates will lose their only opportunity for lifesaving treatment. Contemporary evidence confirms pancreas transplantation is not simply life-enhancing but lifesaving (PMIDs: 25629390, 37402977, 19730242, 31553823). Of the 92,942 kidney candidates currently listed, only 2,328 are SPK (2.5%), and just 733 received a kidney via SPK in 2024 (Pediatric kidney candidates also deserve priority for high-quality donors, but they face different circumstances. They represent a smaller population, can often wait for the best match, and have dialysis and retransplant options available. They also have greater access to living donation than the SPK population. By contrast, pancreas candidates lack any equivalent to the kidney safety net policies that already protect liver, heart, and lung multi-organ candidates (PMID 37379084). SPK candidates deserve similar safeguards.

Regarding the allocation sequence, for DBD donors aged 18–69, I support maintaining SPK priority over pediatric kidney transplants, consistent with current practice. For DBD donors aged 11–17 with KDPI 0–34%, the data strongly favors SPK priority. Table 5 shows Pancreas/KP 4 (250NM) appears in a median of 28 match runs, compared with just 3 for pediatric kidney. If the Committee intends to rely on appearance frequency, its own data support placing Pancreas/KP ahead of pediatric kidney in this category.

If these kidneys are consistently allocated to pediatric candidates first, SPK patients will lose their rare window for transplant. Pediatric candidates can bridge with dialysis and pursue re-transplantation; pancreas candidates—especially those with brittle diabetes—often cannot.

Maintaining Pancreas/KP 4 ahead of pediatric kidney in this allocation sequence is consistent with the Committee’s data, advances fairness and equity, optimizes organ utilization, and maximizes overall patient benefit.

Sandra Amaral | 09/29/2025

Please consider moving pediatric kidney candidates ahead of KP candidates. Specifically, in the table row 34 non-sensitized KP candidates are placed ahead of children awaiting kidney alone (row 35). In our region, we consistently have pediatric candidates who endure longer waiting times because we are not getting high-quality, well-matched kidneys that we accept because they are allocated to KP and MOT candidates prioritized ahead of children.

Please consider allocating one kidney to an MOT (including KP) and one kidney to a kidney alone candidate when two kidneys are available. Kidney candidates are waiting too long for kidneys and enduring prolonged hardships of dialysis.

Please also consider that centers need to decide on acceptance more quickly.
In recent times, we have experienced more delays in organ acceptance. It is common for our pediatric candidates to be back-ups awaiting decisions on MOT placement. However, on more than one occasion, by the time the status of the MOT was decided (declined for MOT) and the kidney became available, too much time had elapsed such that the kidney was no longer suitable for a child. If a high-quality, well-matched kidney becomes available for a child, that should be fast-tracked, especially if/when the child is on dialysis.

Lorrinda Gray-Davis | 09/29/2025

Strongly Support

OPTN Ethics Committee | 09/29/2025

The OPTN Ethics Committee thanks the Ad Hoc Multi-Organ Committee for its work on this proposal and for the opportunity to provide input. Kidney allocation policies in the proposal aim to prioritize candidates comprised of highly sensitized patients, pediatric patients, and patients with high medical urgency, whether they are in need of a solitary kidney or more than one organ. The current system, by contrast, prioritizes multi-organ candidates over kidney alone candidates, which in practical terms often leads to longer wait times to the next offer for kidney alone candidates. In this respect, the proposal seems to make things fairer for all candidates across the board, while improving access for vulnerable populations. This noted, the white paper would benefit by providing greater and more explicit detail about the trade-offs between the existing and proposed policies, spelling out the potential ramifications for kidney alone candidates versus multi-organ candidates, if only to refute the perception held among some that the proposal may introduce greater disadvantages for patients awaiting kidney-only transplants. The committee additionally notes that the proposal’s emphasis on medical urgency introduces compelling questions about how need is prioritized across organ types, which in itself merits further exploration and public dialogue.

HonorBridge | 09/29/2025

There is overall support for the proposal and appreciation for the committee's work to create consistency and a framework around multi-organ allocation. While we support the overall concept of the proposal, we ask for the committee to consider striking a better balance with the structure of the allocation table and the flexibility needed on certain donor situations. For example it may not always be possible to have HLA before starting allocation and some brain dead lung donors may need further management before allocation begins. How can we accommodate these such situations while maintaining the structure of the allocation table? It would also be important for transplant centers to be able to see the allocation table sequence so they would be able to better anticipate their PTR's priority on the match.

Rebecca Baranoff | 09/29/2025

Support

OPTN Organ Procurement Organization Committee | 09/29/2025

The OPTN Organ Procurement Organization Committee appreciates the opportunity to provide input on the OPTN Ad Hoc Multi-Organ Transplantation Committee’s proposal and provides the following comments for consideration:

• The Committee supports the updated language changing “permissible” or “not permissible” to “must” or “must not” when making organ offers, as the new terms provide more clarity for OPOs on what organs they can offer.

• The Committee suggests adding the number of times an organ is accepted and then unaccepted by a center to the key metrics for evaluation of the implementation of this policy.

• The Committee noted that the requirement for HLA completion before generating the multi-organ allocation plan would generally not be an issue; however, there are circumstances where it may pose a problem. The Committee wants to know if, in those instances, the system would block the OPOs from making offers or if they would be in violation if they did need to make offers in those circumstances.

• The Committee supports the policy change but cautions that close monitoring of this policy and the ability to adjust the policy quickly if it is not working will be critical to success.

The Committee appreciates the opportunity to provide their feedback on this project and looks forward to further collaboration on the topic with the MOT Committee.

John Hodges | 09/26/2025

Well thought out, and once implemented we can learn how to make it even better! The issue I hope is addressed before implementation has to do with the Kidney 5 category for living donors, which, while not equivalent to the erroneous shorthand, "you'll be at the top of the list!" we hear donor candidates are still told, it's certainly understandable based on the medical needs of those with higher priority. That's fine, but where are the other living donors? Liver donors, lung donors, pancreas donors, and more? Thank you!

American Society for Histocompatibility and Immunogenetics (ASHI) | 09/26/2025

The American Society for Histocompatibility and Immunogenetics (ASHI) and its National Clinical Affairs Committee (NCAC) appreciate the opportunity to provide feedback on this update. ASHI supports the establishment of a standardized approach to multi organ allocation. ASHI supports the proposal to consider a priority to certain groups of single organ candidates such as pediatrics, medically urgent and highly sensitized candidates. A computer-generated tool and training are essential to promote transparency in the allocation process. Since this allocation would cover 80-90% of cases, exceptions should be specified, for example, proximity, prior living donors, etc.

VA Pittsburgh Healthcare System | 09/26/2025

Support

OPTN Heart Transplantation Committee | 09/26/2025

The OPTN Heart Transplantation Committee (Committee) thanks the OPTN Multi-Organ Transplantation (MOT) Committee for seeking the Committee’s input regarding the policy proposal, Establish Comprehensive Multi-Organ Allocation. The Committee acknowledges and appreciates the MOT Committee’s substantial amount of effort developing the proposed multi-organ allocation tables and focusing on comparing medical urgencies across organs. The Committee members concurred with the proposal’s general principles as indicated by the multi-organ allocation tables presented. Committee members indicated that certain adult heart status 4 candidates, such as Fontan patients and amyloid patients who also need liver transplants, may be disadvantaged because the proposed allocation tables do not include classification rows addressing adult heart status 4 candidates but do allocate livers to a group of mostly liver only candidates before the transition to traditional match run allocations begins. As a result, such candidates will likely have to be admitted to their transplant hospitals and wait substantial amounts of time before receiving offers or a transplant, according to the Committee members. In light of this, the Committee requests that the MOT Committee consider adding adult heart status 4 candidates to the proposed allocation tables, even as the last classification rows of the tables, if an additional round of public comment is not required. The members indicated that doing so will ensure that such candidates are prioritized as multi-organ candidates. The members appreciated the explanation that if the heart remains unplaced after the multi-organ allocation tables have been completed, the OPO would continue making offers down the heart match run, including to multi- and single-organ candidates in the order they appear on the match. Additionally, the Committee requests that the MOT Committee’s monitoring plan specifically address the impact on all categories of adults heart status 4 candidates, especially single-ventricle candidates. And that the monitoring plan evaluate and report how many heart-liver transplants are performed as in-patient versus out-patient procedures.

International Society for Heart and Lung Transplantation | 09/26/2025

Please reference attachment.

View attachment from International Society for Heart and Lung Transplantation

OPTN Lung Transplantation Committee | 09/26/2025

The OPTN Lung Transplantation Committee thanks the OPTN AD Hoc Multi-Organ Transplantation Committee for their work to bring clarity and consistency to multi-organ allocation. The Committee supports establishing standardized MOT allocation tables to replace OPO-by-OPO discretion and improve transparency. Additionally, the Committee supports inclusion of a high Lung Composite Allocation Score (CAS) tier to help ensure priority access for the sickest lung and heart–lung candidates.

Regarding Allocation Out of Sequence (AOOS) the Committee agrees that the proposed tables should reduce AOOS while they govern offers. The Committee recommends explicit post-implementation monitoring of AOOS, including reason tracking that distinguishes events occurring in sequence with the MOT tables from true irregularities to assess whether policy intent is achieved and where refinements are needed.

The Committee expressed concern regarding the cross-organ allocation system comparison challenge, as total Lung CAS incorporates post-transplant components, whereas other organs’ top tiers are more heavily weighted toward waitlist urgency. The Committee appreciate the MOT Committee’s attempt to set thresholds that respect relative clinical priority encourage ongoing evaluation of the lung thresholds after implementation to confirm they are performing as intended.

Family Lifestyle Solutions LLC | 09/26/2025

As a Social Worker and community liaison I am happy to know that there are focus groups and organizations working on behalf of organ donor. From what I read, it seems like there are some gaps and how the allocation of organ transplants are done, and I would like to see that system updated to prevent any loss of organs that should go to someone to save their lives.

Vanderbilt University Medical Center | 09/25/2025

On behalf of Vanderbilt Transplant Center, we appreciate the opportunity to provide feedback on this proposal. In general, we support the initiative to establish a comprehensive multi-organ allocation policy, and especially the emphasis placed on prioritizing groups who have been historically disadvantaged within the current system.
Given the potentially significant impact of unintended consequences, we believe it is essential to conduct further analysis—such as sampling, trialing, or retrospective modeling—to fully understand the implications of the proposed new system. A deeper understanding of the proposed changes prior to implementation will help ensure that this new system is both sustainable and effective in advancing the stated objectives.

American Nephrology Nurses Association (ANNA) | 09/24/2025

ANNA agrees. We support a comprehensive, standardized multi-organ allocation policy for consistency and efficient access across all OPO’s. 

Region 5 | 09/24/2025

Sentiment: 8 strongly support, 18 support, 0 neutral/abstain, 0 oppose, 0 strongly oppose

Comments: One attendee commented that the examples provided were incredibly helpful, noting that policy does not truly come to life until it is seen in practice. They emphasized that post-implementation monitoring will be essential and pointed out that the OPTN and MPSC do not currently have the same monitoring for post-transplant outcomes in multi-organ transplant (MOT) as they do for single-organ transplant (SOT). They questioned whether the committee was comfortable moving forward without equivalent regulatory monitoring. Another attendee thanked the committee for its hard work and said the only way to understand what is happening is to have a system that allows it to be studied. They added that it would be helpful to have guidance for situations where plans change, since MOT cases are most likely to change at the last minute due to many factors. They added that perfect should not be the enemy of good and raised a question about differences in point assignments, noting that the Kidney Allocation Score (KAS) gives blood group O candidates five additional points, while the difference here is four, and wondered if that was intentional. One attendee commented that it will be important to follow the impact of this policy on all groups, emphasizing concern about further barriers to pancreas transplantation given the already declining numbers of pancreas and kidney/pancreas transplants. Another attendee said they supported the concept but found it difficult to evaluate based on the presentation. They expressed concern that the proposal might slow allocation, putting kidneys already allocated too late at higher risk of non-utilization, and worried that kidney-only candidates could face additional delays. Another attendee stated that they only support multi-organ allocation if it does not disadvantage patients with high cardiac status (statuses 1 and 2) or lung candidates with a Composite Allocation Score (CAS) greater than 40. One attendee questioned why living kidney donors had moved so far down on the kidney allocation list. An attendee proposed that the highest organ severity index should lead the allocation order. Using the example of a heart-lung transplant, they explained that a candidate with a high CAS and a status 3 heart must currently wait for the heart allocation to be completed before receiving the combined organ. They expressed agreement with the proposed changes, particularly with a lung CAS threshold of 3 depending on donor blood type O. They stressed that careful attention must be paid to avoid disadvantaging patients listed for a single organ but at a very high status, such as a status 1 liver or a high MELD score for liver, compared to multi-organ candidates.

Region 10 | 09/24/2025

Sentiment: 4 strongly support, 13 support, 2 neutral/abstain, 0 oppose, 0 strongly oppose

Comments: An attendee from the pediatric community noted that standard kidney-pancreas (KP) candidates continue to be prioritized above standard pediatric kidney-alone candidates, which disadvantages children, particularly when programs are located near large adult centers. This was identified as a significant pain point that the proposal aims to address. Concerns were also raised about how MOT allocation is managed when family or organ constraints exist, including how late declines should be handled and whether allocation decisions would be based on offers available at the beginning or end of the process. OPO representatives expressed that without a single match run integrating all organs, flipping between separate match runs is confusing and increases the risk of errors. Questions were raised about the robustness of the data informing prioritization sequences, including whether waitlist mortality, post-transplant survival, or utility were factors. Attendees also asked how feasible it would be to align this policy with future transitions to continuous distribution (CD). Related to thoracic safety nets, concerns were voiced that kidney function after simultaneous heart-kidney transplants often lags, leading to questions about whether allocating the heart alone and relying on the safety net might be more effective. There was broad agreement on the importance of standardization across OPOs, but also recognition of the operational and programming challenges. Attendees stressed that policy implementation should not move forward without clear system functionality to support allocation staff, warning that manual implementation would be impractical. Specific requests included system-generated tables, logic integrated into the OPTN computer system to guide real-time decision-making, and clarity on whether OPOs could override warnings in clinically appropriate cases. Several attendees emphasized that the complexity of the written policy underscored the need for integrated system support. Discussion also touched on how to handle expedited placements, late or in-process declines, and whether OPOs would be expected to re-run lists in time-sensitive scenarios. Concerns were raised about the impact on pancreas versus pediatric kidney prioritization, with calls to ensure pancreas candidates do not drop lower than their current position. Some argued that pediatric candidates should be prioritized above standard KP candidates in certain donor scenarios, particularly given that most pediatric kidney recipients receive kidneys from adult, not pediatric, donors. There were suggestions to consider higher priority for certain pediatric candidates, such as those with longer wait times or elevated but not maximum cPRA, to help address disparities. Several attendees highlighted the broader context, noting that CD had been paused partly due to funding limitations, and questioned whether this MOT policy could realistically be implemented given the significant programming required. Many reiterated that proceeding without adequate system support would undermine consistency and transparency. Overall, there was support for developing a formal and reproducible MOT allocation policy, coupled with recognition that numerous clinical, operational, and technical details remain unresolved. Attendees emphasized the need for a robust post-implementation monitoring plan, ongoing data collection, and careful attention to the impacts on pediatric, pancreas, and highly sensitized candidates.

UW Organ and Tissue Donation | 09/23/2025

UW Organ and Tissue Donation supports the goals of the proposed multi-organ allocation policy to improve clarity, consistency, and fairness in allocation. Our priority is to maximize every donor’s gift, and we agree that standardization can reduce variation and conflict between single- and multi-organ placement.

We believe our past comments remain important about preserving flexibility and considering real-world circumstances. Donors may become unstable, families may have time constraints, or organ function may improve after allocation resulting in a new organ eligible for transplant. The current proposal does not clearly outline how OPOs should navigate these challenging scenarios. Outlining clear exceptions and instructions are essential to ensure this policy achieves its intent while honoring clinical realities, the donor and donor families who make donation possible, and the OPOs tasked with executing allocation in real time. We view this policy as a strong step forward and encourage refinement that ensures compliance and maximizes organ utilization.

OPTN Transplant Coordinators Committee | 09/23/2025

The Transplant Coordinator Committee thanks the Multi-Organ Transplantation Committee for their work promoting equitable access and transparency in multi-organ allocation. The Committee is overall supportive of this proposal and looks forward to seeing this work implemented. Members suggested clear procedure guides and educational materials for both transplant staff and patients/caregivers in order to bridge knowledge gaps. Additionally, members suggested options for programs to run simulations prior to implementation to help transplant staff and patients understand the new system. Overall, the TCC is grateful for the MOT’s continued dedication to creating this proposal.

University of Arkansas for Medical Sciences | 09/23/2025

We appreciate the opportunity to provide feedback on the OPTN proposal to Establish a Comprehensive Multi-Organ Allocation Policy 2025. As a transplant center that performs simultaneous pancreas-kidney (SPK) transplants, we believe that when a viable pancreas is available, priority should be given to facilitating SPK transplants in order to maximize organ utilization and optimize patient outcomes. SPK transplantation provides significant clinical benefit to eligible patients with diabetes and end-stage kidney disease, and prioritizing this approach supports equitable access to care for this population. We also recognize the importance of careful monitoring after implementation to ensure that prioritizing multi-organ transplants does not have unintended negative effects on other transplant candidate populations. Ongoing data collection and transparent review will be critical to assess the impact of this policy change and to make adjustments as needed. Additionally, we agree that comprehensive education and training for transplant professionals prior to implementation will be essential to support a smooth transition and to ensure consistent, equitable application of the new policy across all centers. Finally, we maintain our belief that consideration should be given to transplant centers participating in the IOTA model as organ offer acceptance is a large part of this model and centers are expected to increase their organ offer acceptance rate year over year. Making changes to the organ allocation policies will impact transplant centers offer acceptance rates and integration during the mandatory IOTA model may have negative impacts on transplant centers.

OPTN Pancreas Transplantation Committee | 09/23/2025

The OPTN Pancreas Committee thanks the OPTN Ad Hoc Multi-Organ Transplantation Committee for its work and dedication to developing policy on multi-organ allocation. The Committee would be in support of the proposal should the following issues be incorporated into a final proposal:

The Committee encourages thorough and robust post-implementation monitoring with a focus on dual-organ transplant outcomes as well as pancreas allocation within the proposed tables, as there is a risk of an increase in pancreas non-utilization.

The Committee recommends that, in rare cases of a kidney candidate with CPRA 100% who also needs a pancreas, the pancreas should follow the kidney as a required share, ensuring that highly sensitized KP candidates are not disadvantaged due to being ranked at a lower stratum on the allocation tables.

The Committee recommends that extensive educational offerings be made available to OPOs and transplant centers, especially in scenarios where organ availability changes just before procurement (i.e. in the OR),

Anonymous | 09/22/2025

I first want express my appreciation and applaud the committee's efforts to provide clarity to what has been a challenging and nebulous area in allocation policy.

I echo the concerns of many that the current proposal still inadequately balances the needs of multi-organ candidates with those of single-organ candidates, particularly those awaiting kidney transplantation. However, my current experience has been that single-organ kidney candidates, regardless of their sensitization or other priority, are allocated organs behind **all** other multi-organ candidates. I can cite many instances where a patient at the top of the kidney match run is not allocated an organ until after the donor recovery is completed, due to the possibility that organ could be offered to a multi-organ candidate who was not the primary candidate for their other organ. For example, the liver is placed as a single organ, but the "back-up" candidate is listed for SLK. The OPO waited to formally offer the kidney to the top kidney-alone candidate until after recovery just in case the primary liver center declined in the OR and the liver could then go to the SLK recipient. This creates additional inefficiencies in an already inefficient process.

I would opine that the current policy proposal is no worse than this existing reality, and may provide some benefit to at least some highly-prioritized single-organ candidates. I would urge the committee to take this further, and consider additional prioritization of some single-organ candidates and define how OPOs should handle late declines. In the above example, can the kidney be reserved for the SLK backup PTR just in case; or once the liver was placed with a liver-only PTR, should the kidney be allocated to the kidney list, and in the event of a a late liver decline, the liver is then only available as a solitary organ?

I would also urge the committee to consider the degree to which geography affects the efficiency of organ allocation and how proximity is prioritized in the MOT tables and allocation in general, particularly as we continue to move towards continuous distribution frameworks. Should nearby heart-only and kidney-only PTRs get priority over a heart-kidney PTR across the country? Maybe, maybe not. It probably depends on the status of the candidates. I don't envy the committee's work in sorting this out, but I do believe we currently under-weight proximity in our organ distribution.

Finally, in light of these proposed MOT tables, I would urge the committee to consider simplifying the process of organ allocation by collapsing all allocation to a single match run for all organs. The current proposal will have OPOs bouncing back and forth between different matches and trying to sort out what organ goes where. The proposed MOT allocation tables essentially do this already, by ordering the classifications from the various organ-specific match runs. Collapsing to a single list, combined with the increased clarity this proposal provides around which organs a multi-organ PTR must and must not be offered, would simplify allocation for the OPOs and provide better clarity to transplant centers about the ranking of their PTRs on the match run. Under the status quo, kidney and SPK centers have no way to know if and how many multi-organ PTRs exist for a potential donor, and therefore how many kidneys are expected to be available to the kidney and SPK match runs. Placing all candidates on a single list with the ability to filter views to specific organs would make this far simpler.

Again, I truly thank the committee for their efforts on this very challenging topic and appreciate the opportunity to provide feedback on the proposal.

Gift of Life Michigan | 09/22/2025

We appreciate the work this ad hoc Committee has put into this important project. We also appreciate the effort to improve multi-organ allocation algorithms because it would streamline OPOs’ organ placement efforts. We acknowledge that maintaining equity is challenging when allocation match-runs lack clarity or leave room for interpretation. The proposed match-run scenarios and tables take many scenarios into account.

With recent concerns about Allocation Out of Sequence (AOOS), it is imperative that match-runs reflect policies that fully account for fairness and equity. Allocation of deceased donor organs has become far more difficult when facing the potential loss of donated organs because of the time it takes to work through match-runs, and multi-organ offers not currently well defined create confusion and contention within the system.

We hope the algorithms capture myriad combinations of organs and criteria to ensure that donated organs provide maximum benefit to patients in need, as well as honor the dignity of the donors and their gifts by preventing any potential loss through non-use. We strongly agree with the Committee’s observation that training on any new policy is essential for its success.

We support the concept of better-defined multi-organ transplant allocation.

Neeraj Sinha | 09/21/2025

Following comment is in my personal capacity.

The proposed multi-organ allocation policy requires further attention to several important issues that could undermine its equity goals. One major concern is the strict division at the 18th birthday to determine pediatric versus adult transplant candidate status. This hard cutoff creates the real possibility of substantial disparities for candidates who are otherwise clinically similar, but fall just on either side of this arbitrary age threshold. A more nuanced, gradual approach to this age transition, or explicit safeguards for young adults, would help protect this vulnerable group from loss of transplant opportunity and abrupt changes in priority.
Another uncertainty is the effect of the new allocation tables on waitlist time and mortality, particularly for heart-lung and lung-liver multi-organ candidates. These patients have historically been at high risk, facing longer wait times and elevated waitlist mortality. As the new policy does not offer robust impact modeling in advance, there is a risk these groups could see diminished access or poorer outcomes, which must be actively guarded against in the early period of implementation.
It is also critical to ensure that single-organ candidates who have historically had limited access, such as highly sensitized, medically urgent, and pediatric patients, benefit as intended from the removal of blanket multi-organ priority. Small groups of “straddler” candidates near policy or table boundaries, and rare organ combinations, should be carefully monitored to avoid unintended disadvantages.
Finally, continuous, transparent post-implementation monitoring and public reporting on waitlist time, mortality, allocation out-of-sequence, and the experience of candidates across age thresholds, will be essential. The willingness to rapidly revise the policy in response to emerging data should be explicitly stated. Improving equity in organ allocation requires more than written intent—it demands vigilant outcome tracking and a commitment to ongoing refinement as real-world effects become known.

Region 6 | 09/19/2025

Sentiment: 1 strongly support, 3 support, 3 neutral/abstain, 1 oppose, 0 strongly oppose

Comments: One attendee commented that the proposed multi-organ allocation plan could be a useful guide for Organ Procurement Organizations (OPO) coordinators when donor management, organ evaluation, and allocation proceed in a linear and timely fashion. However, they noted that this type of linear progression is typically the exception rather than the norm, due to changing donor clinical status and varying transplant center acceptance decisions. Several attendees commented that the change would not help transplant centers understand where their single-organ candidates stand when multiple organs are being allocated. They stated this is a major problem for transplant centers and recommended that the match run be modified so centers can see allocation priority. They emphasized that clear, easy-to-follow instructions with color coding would be helpful, and that transplant centers need multi-organ transplant (MOT) sequencing incorporated into the match run so they can see where a patient falls in the MOT sequence. They went on to comment that doing this would be helpful in terms of planning and efficiency. One attendee recommended adding the ability for centers to see all the tables on the allocation plan. Another attendee commented that this could be a useful tool for OPOs, but it may extend case times; adding that one universal match run could be more efficient. Several attendees raised concerns about diverting too many high-quality kidneys to multi-organ transplants, potentially increasing pancreas non-use and disadvantaging CPRA 100% KP candidates. They suggested that the committee look more closely at the KP population. Another attendee also had concerns about the lack of prioritization for CPRA 100% pancreas candidates, diversion of high-quality low Kidney Donor Profile Index (KDPI) kidneys to simultaneous heart-kidney (sHK) and simultaneous liver-kidney/lung-kidney (SLiK/LuK) transplants, which have very high primary non-function (PNF) rates and the resulting decrease in access for kidney-alone candidates. One attendee commented that it is unclear exactly how this policy will be executed, adding that this policy should not further increase the non-use rate as other allocation changes have done. An effective policy also needs to be clearly understandable and support the allocation process without further lengthening the organ case times. Another attendee commented that this has been much needed as a clear as possible multi-organ plan would help with transparency for transplant hospitals and OPOs.

OPTN Histocompatibility Committee | 09/15/2025

The Histocompatibility Committee thanks the Multi-Organ Transplantation members for their dedication towards creation of multi-organ allocation policy. The Committee has the following feedback:

The Committee is interested in seeing more data on currently how many allocations occur without HLA typing, as this policy would require HLA typing to be performed before generating the multi-organ allocation plan. Members added that the efficiency of match runs is decreased without HLA typing.

Members also added that there may be concern for increasing allocation variances given the turnaround time of HLA typing for multi-organ allocation plans involving kidneys. They Committee looks forward to seeing post-implementation monitoring data on instances where multi-organ allocation plans could not be followed because HLA typing was unavailable.

Finally, members added that community education on listing unacceptable antigens for multi-organ allocation plans would be helpful for lab compliance of this policy.

Overall, the Committee agrees that this is very important work for standardizing multi-organ allocation, and members look forward to seeing this proposal implemented

Anonymous | 09/14/2025

There should be a place where a person can register to NOT be a donor with there picture that noone can change, so it can stop organ trafficking

OPTN Living Donor Committee | 09/12/2025

The OPTN Living Donor Committee thanks the Ad Hoc Multi-Organ Committee for its work on this proposal and the opportunity to provide input. The Committee reaffirms its longstanding support for prioritizing prior living donors in organ allocation policy. While this group represents a relatively small portion of candidates, the impact of such prioritization is significant and meaningful. The committee advocates for extending this priority across all organ types—not just kidney and lung—to more fully honor the contributions of living donors.

In response the a question about the inclusion of heart and liver donors under future policy frameworks, it was confirmed that the allocation tables have been designed to accommodate future policy changes, including the potential expansion of donor prioritization. The current placement of prior living donors within the allocation tables was also discussed. Changes to the placement of living donors on the tables would require shifting entire classification groups to maintain consistency with existing policy.

The Committee encourages further exploration of how policy can more fully recognize and honor prior living donors, and supports adjustments that reflect their unique contributions to the transplant system.

Region 7 | 09/12/2025

Sentiment: 3 strongly support, 11 support, 1 neutral/abstain, 1 oppose, 1 strongly oppose

Comments: Several comments emphasized the need for flexibility when donor circumstances change. Questions were raised about whether a match run must be rerun if an organ initially considered ineligible improves, and whether provisions exist for donor instability or family time constraints. OPOs stressed that real-world scenarios could create the appearance of non-compliance unless clear mechanisms for case-specific exceptions are included. Kidney-pancreas (KP) and pancreas-alone (P) transplantation drew particular focus. Multiple attendees noted that only about 10% of pancreata are usable, and that the majority are transplanted as SPK (simultaneous pancreas-kidney). Concerns were expressed that the proposed policy may further reduce SPK numbers, increase wait times, and exacerbate delays in allocation. Attendees emphasized that SPK candidates face high mortality, lack the safety net options available to heart-kidney (H-K) and liver-kidney (L-K) candidates, and should not lose priority relative to other multi-organ groups. Some suggested adding stringency to H-K and L-K eligibility to limit overuse and protect SPK opportunities. There was also a call to better align pancreas prioritization with kidney candidates who are highly sensitized (cPRA 100%), as current criteria disadvantage pancreas candidates despite their dual status as kidney patients. Allocation tables were another area of debate. Several argued that donor characteristics such as age, diabetes status, and BMI should be used to prioritize allocation appropriately, avoiding unsuitable donors for pancreas/KP candidates while prioritizing young, non-diabetic donors for SPK. Some objected to the KDPI cutoff and age criteria, arguing they were misaligned with clinical practice. Others noted that pediatric DCD donors were not included in the tables and asked why. Beyond organ-specific issues, participants highlighted broader concerns about education, implementation, and system efficiency. Transplant centers and OPOs will need education to understand and explain the system, particularly for multi-visceral candidates. There were worries about slowing allocation, increased cold ischemia time, last-minute switching between allocations, and overall inefficiency. Suggestions included pre-implementation simulations of allocation scenarios in the OPTN system to test the logic of the new tables. While some institutions expressed support for the proposed order of priority, others opposed it, particularly in how candidate groups were ranked within the multi-organ allocation tables. Hospitals advocated for preserving flexibility, ensuring fairness, and protecting disadvantaged groups, including pediatric candidates, long-wait kidney-alone candidates, and highly sensitized pancreas recipients. Overall, attendees agreed that the proposal represents important progress toward standardization, fairness, and clarity in multi-organ allocation. However, they stressed the importance of monitoring post-implementation outcomes, protecting vulnerable groups such as SPK and pediatric candidates, ensuring OPOs can operate within real-world constraints, and preventing further reductions in pancreas utilization.

Region 8 | 09/12/2025

Sentiment: 4 strongly support, 10 support, 4 neutral/abstain, 1 oppose, 0 strongly oppose

Comments: An attendee noted a lack of visibility in current kidney match runs, where kidneys are often allocated to multi-visceral candidates without appearing on the match run, and requested greater transparency in the OPTN computer system at the time offers are made. There was also concern about the complexity of the proposal, drawing parallels to challenges in lung continuous distribution and cautioning against potential programming errors. Questions were also raised about the “must/must not” designations, with some suggesting they could cause confusion. Process considerations were a recurring theme, with suggestions that abdominal organ match runs be run first, though attendees acknowledged this might slow allocation overall. While the standardized approach across OPOs was welcomed, several emphasized that allocation changes often create unintended ripple effects across the system that cannot be fully modeled in advance. Some attendees stressed the importance of focusing on high-priority single-organ candidates and cautioned that subgroups such as Fontan patients requiring heart-liver or heart-kidney transplants are not adequately accounted for in the current framework. Post-implementation analysis was seen as necessary to assess potential unintended consequences for these at-risk populations. Pediatric representation was a focus, with strong support expressed for prioritizing pediatric candidates over some multi-organ combinations. Attendees noted that pediatric patients face longer wait times and reduced transplant rates compared to previous years, particularly for kidney transplants, where suitable high-quality organs are often allocated to multi-organ recipients instead. Prioritization for pediatric candidates would improve equity and long-term outcomes. Attendees recognized the importance of standardizing multi-organ allocation and acknowledged the substantial effort behind the proposal, but they cautioned that the changes add complexity, could increase inefficiencies in allocation time, and may leave important subgroups at risk without further refinement and careful monitoring after implementation.

Region 11 | 09/11/2025

Sentiment: 3 strongly support, 15 support, 5 neutral/abstain, 1 oppose, 0 strongly oppose

Comments: An attendee asked the committee to consider how the policy would apply in expedited allocation scenarios. An attendee noted significant concern about the impact on kidney and kidney-pancreas lists, citing worse graft outcomes in multi-organ recipients. A member asked that the pediatric population be kept in mind during policy development. An attendee stated that pediatric candidates listed before age 18 are not adequately prioritized and should be placed ahead of SPK candidates, and requested that single organ match runs indicate when a donor is part of a multi-organ allocation plan to improve awareness for pediatric kidney teams. A member requested guidelines for cases where a center accepts multiple organs but transplants only one, asking how this would be monitored and whether reallocation would be possible. An attendee suggested that when two organs are placed, one kidney should go to the kidney or KP match run and the second to multi-organ and expressed appreciation for the 500nm allocation. A member recommended post-implementation monitoring of transplant rates for highly sensitized candidates and asked the committee to consider situations where organ usability changes during donor management, and how OPOs should handle allocation timing. An attendee supported the policy but was disheartened by the lack of prioritization for pediatric candidates and emphasized the need to prepare for impacts on expedited DCD allocation. A member supported a standardized process but stressed the importance of maintaining options for donors with limited allocation time and preserving the benefits of safety net policies. An attendee supported the work behind the policy and emphasized the need for thoughtful implementation and education, expressing concern about increased multi-organ transplants that could bypass the safety net, while also recognizing the need for improved transparency and access for multi-organ candidates.

OPTN Liver & Intestinal Organ Transplantation Committee | 09/11/2025

The OPTN Liver & Intestinal Organ Transplantation Committee thanks the OPTN Ad Hoc Multi-Organ Transplantation Committee for their efforts on the Establish a Comprehensive Multi-Organ Policy 2025 proposal. The Committee commends the work undertaken by the members of the Multi-organ Transplantation Committee to address an important topic. The Committee expresses gratitude that the project is moving forward.

The Committee supports this proposal. The Committee encourages the Multi-Organ Transplantation Committee to include evaluation metrics related to out of sequence allocation in the post-implementation monitoring plan.

The Committee is interested in having the Multi-Organ Transplantation Committee address late reallocation circumstances that include medically urgent multi-organ transplant candidates.

The Committee notes that the changing landscape for DCD organ offers may present new challenges with current multi-organ allocation schemes.

Region 3 | 09/10/2025

Sentiment: 0 strongly support, 8 support, 2 neutral/abstain, 0 oppose, 0 strongly oppose

Comments: Several attendees commented that prior living donors should get more priority, particularly for low KDPI kidneys. One attendee commented that some multi-organ transplant (MOT) candidates, such as liver/kidney or heart/kidney recipients, may still have significant kidney function and could receive young, high-quality kidneys that kidney-alone candidates might benefit from more. They went on to recommend the committee consider this in MOT match runs to ensure kidney-alone candidates gain more access. Some attendees recommended monitoring late turndowns and whether prior living donors are being disadvantaged after implementation. One attendee commented that the proposal is not ready, noting issues with the allocation tables and missing considerations for certain MOT types, such as SPK. Several attendees commented that a mockup of the allocation table was needed to help OPO staff better understand and provide feedback on the proposal. One attendee commented that they were concerned that patients may increasingly list for MOT just to gain priority.

Glenna Frey | 09/10/2025

Support with follow-up evaluation to determine outcomes of the change.

LifeSource | 09/09/2025

Question 1: We support the standard process as shared
Question 2: We believe the challenges were already stated - need a strong education/training plan and assurance that the system used will function correctly
Question 3: Concerns around solitary kidney and pancreas as was mentioned in the chat during the meeting.

Anonymous | 09/08/2025

While I recognize the complexity of care for multi-organ transplant candidates, I do not support granting blanket priority over solitary kidney candidates for kidney allocation. Such a policy risks disadvantaging patients with end-stage renal disease (ESRD), who have no other treatment option beyond kidney transplantation.

Diverting kidneys to multi-organ recipients could increase mortality among solitary kidney candidates, particularly among minority and medically complex patients who already face significant disparities. Additionally, kidney graft survival is generally lower in multi-organ transplants compared to kidney-alone transplants. Allocating scarce kidneys to settings with poorer long-term outcomes is, in my view, not the most effective use of these limited resources.

Anonymous | 09/05/2025

Clarifying the approach to multi visceral allocation on each donor would be tremendously helpful for OPO staff. A donor-specific multi-organ allocation plan would benefit OPO professionals and ensure compliance with policy. Current multi-organ allocation cases can take a great deal of time which can lead to chaos and potential AOOS in order to ensure non-use is avoided.
Having a policy that is better understood but also allows for flexibility due to the various characteristics and challenges that are OPO-specific is something all OPO professionals should welcome.

Anonymous | 09/03/2025

This policy disadvantages the most disadvantaged group. Kidney alone and SPK candidates have the longest waiting time, and are the only group listed NOT based on urgency. To prioritize kidney allocation over kidney alone and SPK candidates based on urgency criteria toward multi-organ is ethically not justifiable to this extent. At this time, we have ample proof in the literature that these kidneys average over 15 years of excellent function in kidney alone and SPK recipients (better in fact, in SPK recipients than kidney alone recipients). Yet the multiorgan tables give preferential access to kidneys for hearts, lungs, and livers, then kidney recipients with a high PRA where failure is also most common. Multi-organ kidneys have MORE primary non-function and early patient/graft loss than most stable, low EPTS kidney or KP candidates. Many life-years of productivity and quality will be lost for the kidney and SPK population in this proposal.
Please STRONGLY consider modifying the proposal to either: - give priority access for ONE kidney from each multi-organ donor to go the kidney alone or SPK list (this WILL improve pancreas utilization also), or - listing SPK candidates with PRA>80% above heart, lung, liver, or kidney candidates, or - allowing the pancreas to follow highly sensitized kidney candidates (even this would increase SPK utilization) - or consider making a rule that no kidney alone or SPK candidate can be skipped over from a multiorgan donor more than once during their active listing time.
At the very minimum, there should be an obligation to monitor kidney outcomes after heart-kidney, lung-kidney, and liver-kidney - and if the kidney outcomes are inferior in multi-organ, the policy should be revised in favor of kidney alone and SPK. There can be an increase in simultaneous extrarenal organ-living donor kidney transplant if centers are forced to grow this (think pancreas after living donor kidney) - this could be living donor after heart, lung, or liver.
Lastly, there is a safety-net for a kidney after heart, lung, or liver transplant. There is no safety net access for a kidney after pancreas alone transplant - and we are adding this policy to remove access to SPK further by giving good kidneys to other organs first. This really leaves kidney and SPK candidates at a significant disadvantage.

Anonymous | 09/03/2025

This proposal is unfair to kidney candidates. Half of all kidney patients die within 5 years of starting dialysis. The wait time for a kidney is so long, that making it to transplant is hard. Good kidneys are harder and harder to get from the list. Who wants a kidney that will work for only 5 years with damage from diabetes and high blood pressure or drug use that will work poorly and fail in less than 5 years? Kidney patients should have a right to get good kidneys from the healthiest donors, so these kidneys should go to good kidney recipients, where they can function well for decades. Hearts, lungs, and livers can get transplanted with those organs first, as single organs. If those patients, and their organs do well, the patients can stay alive, get dialysis (same as all of us kidney patients) and wait in line with us, or get themselves a living donor. Where is the safety-net for kidney patients? Maybe at least let no kidney recipient be left out twice on account of multi-organ transplants? I feel like kidney patients get pushed further and further behind on account of making all the other organs successful. It's a shame.

Anonymous | 09/01/2025

It is well recognized that simultaneous multi organ transplant recipients do not have the same survival as kidney-alone transplant recipients (and non-kidney transplant recipients have lower 1yr survival than kidney alone recipients overall). In fairness to the >500,000 people on dialysis, MOT should be minimized, except in the pediatric situation, where limiting sensitization and decreasing acute rejection are an important benefit. MOT candidates should not have access to low KDPI kidneys above children and prior living donors, two groups who deserve priority access. We should be using a "safety net first" approach for MOT and they should receive the KDPI kidney that they would have been eligible for had they been a kidney alone candidate.

Anonymous | 08/30/2025

From what I understand a change is needed to particularly mitigate the burden of work on OPOs and increase transparency in the allocation process. A standardized set of allocation rules, in theory, can do this.

My main concern is: Does this policy change potentially further disadvantage candidates with more complex socioeconomic and geographic risk factors that might not be clear or obvious using KDPI, CAS, etc. scores for different organs? And, if this is not answerable or known, can the policy include this consideration in their evaluation and revision criteria for further policy improvement in the year(s) to come, if approved as proposed here?

My concern comes from blanket assumptions that one type of organ need is always more critical than another. I am particularly concerned because as a transplant recipient I have seen and received drastically different care in different hospital settings, but this does not show up always in my scores. That is - at some times of my life I could better burden or be better supported than others, regardless of my medical condition.

I also have had different levels and types of healthcare in my life. I can foresee situations where some transplant candidates - due to limited access to higher quality care, or more restrictive healthcare and care support - will suffer more than someone who lives in vicinity to or who can access higher quality care despite potentially suffering.

I ask this question with the value of equity and accessibility in mind, and with a sensitivity to the practicability of a standardized system yet the need to always have an alternative decision-making model in the event that a standard is not as inclusive in practice as assumed during development.

Jullie Hoggan | 08/28/2025

Support a system that creates equity and more consistency in allocation. A question : Would this system allow for unusual situations where decisions may be made outside these guidelines with good rationale?

Yes Diaz | 08/28/2025

Yes, in theory, this change may increase access for some single-organ patients — but in practice, it will increase death and non-utilization among multi-organ candidates who cannot survive with one organ alone. I know this from lived experience: at nine years old, I was a pediatric kidney patient who waited six months for my first transplant, and at nineteen, I was a highly sensitized young adult who waited over two years for my second. Even in those circumstances, I would not have chosen to take priority over a patient who needed two organs. I urge the Committee to reconsider — protect pediatric and highly sensitized candidates, yes, but not at the expense of those who need more than one organ to live. A policy that postulates equity in theory must not create inequity in practice.

Simon Horslen | 08/28/2025

Strongly Support

Amanda Salisbury | 08/28/2025

While I support changes to provide more clear guidance, I wanted to ask whether or not the availability of organs from living donors was factored into the order of priority presented here. I am a double living anonymous donor, but I would lean toward prioritizing single or multi organ patients whose donations must come from deceased donors. Single organ kidney and single organ liver patients have more avenues open for donation from family, friends, and Good Samaritans.

Terri Milton | 08/27/2025

Creating a standardized set of rules to implement a multi-organ allocation policy is needed.

Anonymous | 08/27/2025

Strongly Support

Anonymous | 08/27/2025

where does safety net kidney allocation fall in this ranking?

Anonymous | 08/27/2025

Support

Michigan Medicine | 08/27/2025

Support

Anonymous | 08/27/2025

Strongly Support

Anonymous | 08/27/2025

The effort to increase equity in access to highest quality organs is an important one. However, the inclusion of kidney-pancreas as part of the problem with multi-organ allocation - placing below several classes of kidney donors - further disadvantages the kidney-pancreas population.

Pancreas transplantation is the only solid organ transplant to decrease in frequency during an era where we are accomplishing record transplant volumes. Across all centers, pancreas transplant volumes have decreased. Simply put, there are fewer eligible pancreas donors than ever before, reflective of the prevalence of high BMI, medical comorbidities, and substance use. Less than 10% of donors meet consideration for pancreas donation, and even fewer proceed to transplantation. Therefore, when a viable pancreas is available for transplant, utilization should be prioritized by facilitating with simultaneous kidney-pancreas transplant.

I applaud the efforts to prioritize organ allocation for patients with "medical urgency". Pancreas transplant candidates, particularly patients with Type 1 diabetes and associated hypoglycemic events, remain at high medical urgency. Based on the rarity of pancreas transplant, frequency of pancreas utilization should not significantly impact access for medically urgent kidney recipients. Without prioritization to utilize pancreas allografts through SPK transplant, access for diabetic patients will continue to lack equity.