New multi-organ policies are in effect
The Organ Procurement and Transplantation Network Ad-hoc Multi Organ Transplantation Committee has implemented several safety net policies to ensure patients in need of multiple organs have priority for a lifesaving transplant. Frequently asked questions about safety net policies are listed below.
What is a safety net policy?
- A safety net policy is for candidates who may not meet eligibility criteria for a simultaneous organ transplant, or who were not listed for a multi-organ transplant. For candidates who need a heart or lung transplant and have some renal dysfunction, transplant programs may opt to proceed with a single organ transplant (in this case a heart or lung transplant) in order to allow the kidneys to recover. If the kidneys do not recover in a timely fashion, a candidate may be eligible to receive safety net priority for a kidney transplant.
When are safety net policies being implemented, and when will the multi-organ portion of the policy be implemented? What is the difference?
- The safety net policy for kidney after heart or lung transplant was implemented in June 2023. The simultaneous heart-kidney and lung-kidney components were implemented on September 28, 2023. Refer to the OPTN policy notice for more information.
- The safety net for heart and lung recipients, which was implemented in June 2023, enables heart and lung recipients whose kidneys are not recovering post-transplant to receive priority during kidney-alone allocation. The simultaneous heart-kidney and lung-kidney policy makes certain changes for candidates who need to receive both organs simultaneously.
Is a safety net policy necessary, why not list a candidate for a multi-organ transplant?
- While multi-organ transplants are the only option for some candidates, other candidates experiencing multi-organ failure may only need a single organ to improve the function of the second organ. For example, if a candidate needs a heart transplant and they begin to experience kidney failure, a heart transplant can lead to improved kidney function and eliminate the need for a kidney transplant.
Does this policy eliminate simultaneous heart-kidney and lung-kidney transplants?
- Simultaneous multi-organ transplants will still occur. For adult candidates who meet the medical eligibility criteria, and pediatric candidates registered for both organs, organ procurement organizations will still offer a kidney with a heart or lung. The safety net is for candidates who need a kidney transplant after receiving a heart or lung.
Does this policy change simultaneous heart-kidney and lung-kidney allocation?
- On September 28, 2023, the eligibility criteria were updated to add criteria related to kidney function and to include status 4 and 5 heart candidates. OPOs must offer the kidney along with the heart or lung to candidates who meet the eligibility criteria, but it will still be permissible for OPOs to offer the kidney along with the heart or lung to candidates who do not meet the criteria.
For a candidate that has received a heart or lung transplant, what are the criteria to receive safety net priority for a kidney?
- First, the candidate must be registered on the kidney waiting list prior to the one-year anniversary of their most recent heart or lung transplant.
- Second, on a date that is at least 60 days but not more 365 days after the heart or lung transplant:
- The candidate has a measure or estimated CrCl or GFR of 20mL/min or less, or
- The candidate is on dialysis.
How long will the candidate remain at the safety net priority?
- When the transplant program reports the candidate meets the criteria, they will remain at this classification for 30 days from the date of the qualifying test or treatment.
- If the transplant program reports another qualifying test or treatment, the candidate will remain at this classification for another 30 days from the date of the most recent test or treatment.
- If the transplant program reports that the candidate meets the criteria for 90 consecutive days, then the candidate will remain at this classification until they are removed from the kidney waiting list.
What impact does the former use of race-based eGFR have on candidates who might qualify for the safety net?
- A candidate whose registration date was backdated prior to the one-year anniversary of their initial transplant due to the eGFR policy change, and meets all other qualifying criteria, would be eligible for safety net based on the current system function. The transplant program must still report dates, whether the candidate is on dialysis, and/or the CrCL or GRF less than 20 mL/min, in 30 day intervals.
Are candidates who received a heart or lung transplant prior to the implementation of the policy eligible for the safety net?
- The policy is retroactive. Candidates who received a heart or lung transplant prior to implementation, and met the criteria for eligibility within the timeframe specified in policy, will be eligible for the safety net.
- Example: Mark received a lung transplant on December 28, 2022.
- On April 27, 2023, Mark was added to the kidney waiting list.
- On May 18, 2023, his CrCl was less than 20mL/min.
- On June 18, 2023, his CrCl was still under 20 mL/min.
- On June 29, 2023, Mark became eligible for the safety net upon implementation.
- Had Mark received his lung transplant in February 2018, met the CrCl criteria between June and September 2018, and had been listed for a kidney in October of 2018, Mark would still be eligible for the safety net upon implementation.
- The requirement to have been registered on the kidney waiting list within 365 days of the heart or lung transplant still applies. As such, if Mark received his lung transplant in February 2018 and was registered for a kidney in June 2023, then Mark is not eligible for the safety net.
If a candidate transfers to a new program, will their safety net status follow them?
- Yes, as long as the candidate’s former center does not remove them from the waitlist prior to the transfer and the candidate has achieved the permanent safety net status. Be sure to communicate the transfer between the two centers to ensure the candidate is not removed by their original center before the transfer is complete.
- Example: Peggy received a heart transplant at Transplant Hospital X on the west coast. She felt better but her kidney function did not improve the way her and her doctors had hoped. 70 days after her heart transplant Peggy began dialysis and was added to the kidney waiting list. Transplant Hospital X submitted the correct safety net qualification report every 30 days. After 90 days Peggy gained permanent safety net status. Six months after her heart transplant, Peggy moves to the east coast and transfers her care to Transplant Hospital B. Since Peggy is still on the kidney waiting list, and was not removed by Transplant Hospital X, her safety net status moves with her to the east coast at Transplant Hospital B. Because Peggy reached the 90 day mark, Transplant Hospital B will not need to enter any qualifying information. Had Peggy transferred to Transplant Hospital B prior to meeting safety net criteria for 90 consecutive days, Transplant Hospital B would need to enter in all qualifying information after the transfer is complete.
If a candidate is listed at more than one center and qualifies for safety net priority, do they qualify at each center?
- A candidate who is listed at multiple centers can qualify for safety net priority at each center at which they are listed. Each center must separately enter the qualifying data and list the candidate on the kidney waiting list within a year of the original heart or lung transplant.
Under the new policy, if a candidate does not meet the eligibility criteria for required simultaneous heart-kidney or lung-kidney offers, does this mean the OPO cannot offer the kidney with the other organ?
- OPOs must offer to eligible heart-kidney or lung-kidney candidates before making offers to kidney-alone candidates. The OPOs do have discretion to offer both organs to candidates who do not meet the eligibility criteria.
Still have questions?
Reach out to member questions at [email protected].
