Frequently asked questions about the removal of donation service area (DSA) and OPTN region from kidney, pancreas, kidney-pancreas and islet allocation

Why are DSA and region being removed from kidney, pancreas, kidney-pancreas and islet allocation?

These changes to kidney and pancreas allocation were developed as a result of the OPTN Board of Directors’ 2018 directive that organ-specific committees remove DSA and region from allocation policies to align with the OPTN Final Rule. One of the requirements of the Final Rule is that policies “shall not be based on the candidate’s place of residence or place of listing, except to the extent required” by other requirements of the Rule.
The goals of these changes are to eliminate the use of DSAs as units of distribution and increase geographic equity in access to transplantation regardless of a candidate’s place of listing, while limiting transportation time and costs, logistical complications, and inefficiencies through the use of proximity points.
Five policies have been implemented that will change how kidneys and pancreata are allocated. Professional toolkits are available with policy documents and other resources.
There are two units of distribution for kidney, pancreas, kidney-pancreas and islet offers: 1) a 250 nautical mile (NM) circle around the donor hospital; and 2) the nation. A nautical mile is approximately 1.15 statute miles; the 250 NM circle is equivalent to approximately 287.5 statute miles (which is the traditional mile measure used when measuring distance over land). Candidates listed inside of the circle can receive a maximum of two proximity points. Candidates listed outside of the circle can receive a maximum of four proximity points.
Statistical simulation modeling projects that the new kidney and pancreas policies will improve transplant access for key groups of transplant candidates, including children, women, ethnic minorities and highly-sensitized candidates.

What impact will these policies have on the existing Kidney Allocation System (KAS) and the Pancreas Allocation System (PAS)?

KAS and PAS were implemented in 2014 and are still in effect. The aspects of KAS addressing prioritization of transplant candidates, including estimated post-transplant survival (EPTS), and of assessing donor longevity potential, including kidney donor profile index (KDPI), have not changed as a result of the 2021 policies affecting kidney distribution.
The removal of DSA and region from allocation alters match sequencing to be based on geographical distance between the donor hospital and the recipient’s transplant hospital of listing.

UNet^SM users can find additional information about changes to system components in the professional education resources on UNOS Connect and in online help documentation in UNet.

For transplant programs

Removal of DSA and region

How do I know if my candidate will fall within the 250 NM circle?

The match distances are calculated using the address of the donor hospital and the address of the transplant hospital where the candidate is listed.
Each classification in the new policy is for candidates who are registered at a transplant hospital located within the listed distance from the donor hospital.
Users may find the “Show distance to transplant center(s)” pop-up useful in determining distance for transplant hospitals. This tool is available in DonorNet^® at the top of the match page.
You can see the donor hospitals located within 250 NM of your program by using this map visualization of donor hospitals within 250 NM of transplant programs.

How are proximity points calculated and displayed?

Proximity points are added to a candidate’s allocation score based on the distance between their hospital of listing and the donor hospital.
Candidates listed inside of the circle can receive a maximum of two (2) proximity points.
Candidates listed outside of the circle can receive a maximum of four (4) proximity points.
Candidates listed at transplant hospitals closer to the donor hospital will receive more proximity points than those listed at hospitals further away. Candidates beyond 2500 NM receive zero proximity points.
The formula for proximity points can be found in the kidney policy notice and the pancreas policy notice.

Allocation of kidneys and pancreata from Alaska

How are donor organs from Alaska handled for kidney and kidney-pancreas match runs, since they are more than 250 NM away from any transplant program?

The Seattle-Tacoma International Airport (Sea-Tac) is a substitute for all Alaskan donor hospitals for purposes of allocation, and act as the center of the 250 NM circle. The system will automatically make this substitution and there is no new action required by users. This change is consistent with changes made to liver and intestine matches.

Reallocation of released organs

Our transplant program is no longer able to transplant the kidney into the intended recipient. Are there any circumstances where policy allows for the kidney to be transplanted into another patient at our hospital?

No, for kidney allocation there is not an option in policy that allows for the transplant hospital to choose an alternate recipient at their hospital. It is the transplant hospital’s responsibility to notify the host OPO and release the kidney back to the host OPO.

New medical urgency requirements for kidney candidates

What does our kidney program need to do to prepare for the new requirements?

It will be necessary to train staff on new processes for obtaining priority for medical urgency.
A medical urgency data collection period took place ahead of the March 15, 2021, implementation. It allowed staff to enter qualifying information for their candidates that meet the criteria under the new policy definition before the policy went into effect.
Professional education resources are available on UNOS Connect.

My kidney patient meets the new medically urgent requirements in OPTN policy. What steps do I need to take to ensure my patients gets the additional priority?

When a candidate qualifies for medical urgency, the transplant hospital should immediately edit the candidate’s medical urgency status to reflect it.
Additionally, the transplant hospital must document the medical urgency qualification in the candidate’s medical record and is required to submit supporting documentation to the OPTN within seven (7) business days of indicating the candidate’s medical urgency status.

Can medically urgent time be transferred between two listings?

Yes, medically urgent time can be transferred between listings, regardless of the status of either listing.

How is medically urgent time used on the match?

Medically urgent time is only used to classify or sort a candidate on the match when the candidate is actively listed as medically urgent.
If there are multiple medically urgent candidates on a match, candidates will be sorted within a classification by their time at medically urgent status, from highest to lowest.

Why is my medically urgent candidate not appearing in the medically urgent classification?

The medically urgent classification only includes candidates within 250 NM of the donor hospital.
If the candidate is highly sensitized or in pediatric classification, they will show in a higher classification than the medically urgent classification on the match.
If the candidate is more than 250 NM away from the donor hospital, they will appear in the appropriate national classification lower on the match. Find more details about classifications in the policy notice.

My candidate already meets new medical urgency requirements. How do I ensure they are receiving time when this project releases?

A data collection period opened seven (7) days prior to implementation. Professional education is available on UNOS Connect to help guide staff through the process.
The data collection period ahead of implementation ensures that candidates are made medically urgent upon project implementation and are not unfairly disadvantaged by programs that take longer to enter this information.
You are be able to check a box when adding or editing a listing in order to enter the candidate’s information and ensure the candidate becomes medically urgent as soon as is possible.

What is considered a contraindication to dialysis in terms of this project?

Policy does not include specific contraindications.
Transplant programs and their vascular surgeons are expected to use their best judgment in making the decision as to whether a method of dialysis is appropriate for their patient based on clinical characteristics including, but not limited to, age, size and anatomical structure.

Will my existing medically urgent and critical status candidates automatically transfer to the new medically urgent status?

No, the new policy requirements differ from those of the existing statuses.
Users are required to enter a candidate’s qualifying criteria in the candidate listing, either during the data collection period or after policy implementation. If medical urgency qualifying criteria has been entered, the candidate will be converted to new medically urgent status upon implementation.
Any candidates in existing Active - Medically urgent (5) or Active - Critical Status (6) statuses will be converted to Active (1) status upon project implementation if medical urgency information has not been submitted.
Temporarily Inactive (7) candidates are not eligible to enter medical urgency qualifying data during the transition period. Candidates must be listed at an active status to qualify for new medical urgency status.

Does medical urgency information expire?

Medical urgency information does not expire. However, if a candidate is made temporarily inactive or converted to a different status, medical urgency information must be reentered in order for them to be made medically urgent again.

Facilitated pancreas allocation information for transplant programs

What has changed for facilitated pancreas allocation?

The yearly update of facilitated pancreas programs will take place with this project and includes data on pancreas transplants from July 2018 – June 2020. The new facilitated pancreas requirements will be programs that have performed at least two (2) pancreas transplants from donors more than 250 NM away from the transplant program within the previous two (2) years.
Transplant hospitals qualifying as facilitated pancreas programs will receive facilitated pancreas offers from donor hospitals outside of 250 NM.

For OPOs

Reallocating released organs (previously known as “local backup”)

As an OPO, we used to assist with importing and helping to reallocate kidneys accepted by transplant hospitals in our DSA that were originally offered by other OPOs. Has this role changed?

Yes. In the event that the original intended recipient cannot be transplanted, the host OPO will have responsibility to allocate the released organ and locate backup recipients.
Importing OPOs (OPOs in the same DSA as the transplant hospital where the organ was placed) are no longer able to initiate a kidney or kidney-pancreas/pancreas import match to identify alternate recipients for these organs. The system will not allow an importing OPO to run an import kidney or kidney-pancreas match because they are no longer permitted per policy.
Importing OPOs may still assist with communication and transportation logistics on behalf of transplant hospitals for imported kidneys if requested by the receiving transplant hospital.
The host OPO retains responsibility for released organs and should follow organ-specific released allocation policies.

What are the options for allocating released kidneys?

Policy stipulates that transplant programs must transplant all accepted, deceased donor kidney(s) into the original intended recipient or release the kidney(s) back to and immediately notify the host OPO or the OPTN Contractor (Organ Center) for reallocation.
The reallocation of these kidneys to alternate recipients is referred to as released allocation. Neither the importing OPO nor the importing transplant hospital play a role in the allocation of released kidneys.
The host OPO is responsible for released allocation of kidneys and may:
- Continue allocation on the original match run
- Allocate using a released kidney match. A released kidney match uses the original accepting transplant hospital as the center of the 250 NM circle rather than the donor hospital.
The OPTN is able to assist with either of the above options. Find more details about released kidney and pancreas allocation in the policy notice.
Find a visual aid and animations of this process on the policy toolkit page.

If a transplant program is no longer able to transplant the kidney into the intended recipient, are there any circumstances where policy allows for the kidney to be transplanted into another patient at that same hospital?

No, for kidneys there is not an option in policy for the transplant hospital to choose an alternate recipient at their hospital. It is the transplant hospital’s responsibility to notify the host OPO and release the kidney back to the host OPO.

Who determines how a released pancreas or kidney-pancreas should be reallocated?

The host OPO determines how to allocate released organs. If the host OPO decides the transplant hospital may find another recipient at their program, they may try to place the kidney-pancreas together or split the kidney-pancreas.
For details on the options available to the host OPO, please refer to the visualization of this process on the policy toolkit page.

The new released organ policy says OPOs may contact the OPTN for assistance in allocating released organs. What does that mean?

The Organ Center is available around the clock to assist host OPOs with the placement of kidneys, including released kidneys. The Organ Center will allocate released kidneys on behalf of host OPOs the same two ways that host OPO staff would—either continuing allocation according to the original match run or according to a new released kidney match. The Organ Center will discuss those two options with host OPO staff, but will ultimately rely on the host OPO to decide and specify which match Organ Center staff will use for the allocation of released organs.
Contact the Organ Center at 800-292-9537 with questions about assistance in allocation.

Facilitated pancreas allocation information for OPOs

Does the allocation of facilitated pancreata change?

OPOs will continue to allocate facilitated pancreata in accordance with OPTN policy, to transplant programs that qualify for these organs. Facilitated pancreas offers may be made once offers have been refused by programs within 250 NM, when no pancreas has been accepted within three hours prior to the scheduled donor organ recovery.

Additional questions?

UNet users can find additional information about changes to system components in the professional education resources on UNOS Connect and in online help documentation in UNet.

For questions about OPTN policy, contact member.questions@unos.org. For questions relating to implementation, email unethelpdesk@unos.org or call 800-978-4334 from 8 a.m. to 7 p.m. ET. The Organ Center is available 24 hours a day at 800-292-9537.