Multi-Organ Allocation: Medical and Ethical Considerations

摘要

Purpose of Review Since the creation of the Organ Procurement and Transplantation Network (OPTN), the allocation of deceased donated organs for transplantation has been guided by the principles of equity, fairness, and utility. Each individual organ has a well-designed policy which generates a list of eligible potential recipients, with a clearly defined prioritization based on their points. While this system works for single organ transplants, there is an increasing incidence of situations where more than one organ is requested for the recipient. Recent Findings These multi-organ transplants (MOTs) are being performed with increasing frequency, and now exceed 2000 cases annually, comprising over 4000 of all organs transplanted. Although some organ combinations, heart-lung and pancreas-kidney, have policy-defined listing criteria and others, liver-kidney, have specific medical criteria, there are multiple considerations regarding the ability more urgent or lifesaving organ being able to "pull" the immediately non-lifesaving organ (most frequently the kidney). Currently, the candidates awaiting a kidney transplant alone have limited opportunity to be stratified for a kidney until the MOT candidates are considered, even to the exclusion of the very highly sensitized candidate. In recent analysis, the majority of kidneys utilized in MOT are those with the greatest potential post-transplant lifespan, which should have been primarily prioritized to the pediatric candidates. We examine the history of MOT and current efforts within the OPTN to address the potential for modification to promote the principles of equity, fairness, and utility. Specific issues were examined, including the prioritization of MOT recipients for the "pulled" organs, the effects on the pediatric kidney waitlist candidates, the data and risk stratification of the MOT recipients as part of the center's Program-Specific Report, and the use of accepted medical criteria, to raise the questions as to how the current policies are comprehensively reevaluated. The need for nationally accepted definitions and criteria within each organ group should be established so as to serve as a common framework for the continuous distribution models currently being proposed. We provide an algorithm for initiating this discussion, with definitions and responsibilities, and the need to encompass all considerations of every organ, including previously OPTN policy-defined combinations, to serve as a discussion template for further dialogue.