Removing DSA and OPTN region from kidney and pancreas allocation
Working together to continuously improve the system, United Network for Organ Sharing and the donation and transplant community have developed new kidney and pancreas allocation policies that will increase equity in transplant access across the U.S. As a mission-driven non-profit, UNOS has always put patients first. We are committed to making transplant opportunities more equitable for everyone waiting for a kidney or pancreas.
Find information about all the Board and committee actions leading up to the adoption of the policies at the June 2020 Board of Directors meeting here.
Increasing equity to benefit patients
The organ transplantation system in the U.S. has never worked better than it does today, but there is still room for improvement. More than 90,000 people are waiting for a lifesaving kidney transplant. 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 candidates who are particularly hard to match for biological reasons.
A Nov. 23, 2020, webinar for patients and their caregivers addressed the changes. A recording is available for viewing here.
Read how UNOS is making kidney and pancreas distribution more fair and equitable by reducing disparities and increasing access for patients.
Optimizing efficiency, improving organ distribution
Developed with input from the community, five separate policies were approved by the Organ Procurement and Transplantation Board of Directors in December 2019 and June 2020 that affect the role of geography in allocation of kidneys and pancreata.
The new policies remove donation service area (DSA) and OPTN region from kidney and pancreas allocation. Instead of using these inconsistent boundaries as units of distribution, kidneys and pancreata are allocated using a 250 nautical mile (NM) circle around the donor’s hospital. This ensures that the system is based appropriately on the medical needs of patients rather than artificial dictates of geography.
In this distance-based allocation system, up to two proximity points are awarded to candidates inside the circle to offer organs efficiently to candidates listed closer to or farther from the donor location. If no candidates inside the circle accept the offer, then up to four proximity points are awarded to candidates outside the circle. Additional policies address how organs from Alaska are allocated and how medically urgent kidney candidates are prioritized in the new system. There have also been substantive changes to how organ procurement organizations (OPOs) reallocate organs that can’t be transplanted into the original intended candidate. Find additional information about the new policies from the resource links at the top of the page.
The road to this policy development involved three public comment cycles and input from thousands of people from across the country. Find information about all the Board and committee actions leading up to the June 2020 Board of Directors meeting here.
What are DSAs?
What are OPTN regions?
Who makes policy?
A step on the path to broader distribution
The success of the national organ donation and transplant system reflects our singular commitment to continuous improvement, which has driven seven consecutive years of increases in the number of transplants performed.
These changes to kidney and pancreas allocation are the continuation of a process to improve distribution of organs, a national lifesource, and are not the final stage in the development of organ allocation policy. UNOS is always striving to continuously improve the system to save more lives through broader distribution of organs.
Frequently asked questions
When were these policies implemented?
Amendments to kidney and pancreas allocation policies approved by the OPTN Board of Directors in December 2019 were implemented March 15, 2021.
Over the past two years, this set of policies has been developed through expert study and multiple rounds of public input and comment. It has been supported by a broad range of clinicians and members of the public, and it was overwhelmingly approved by objective experts in the field of transplantation who are charged with adopting systems to make the best use of donated organs. It is consistent with similar changes already made for all other organ types and advances UNOS’s work to make transplant opportunities more equitable for all people awaiting a kidney or pancreas.
What impact do these changes have on the existing Kidney Allocation System (KAS)?
KAS was implemented in 2014 and is still in effect. The aspects of KAS addressing prioritization of transplant candidates, including EPTS, and of assessing donor longevity potential, including KDPI, have not changed as a result of policies affecting kidney distribution. The changes impact match sequencing in KAS. Instead of relying on DSA and region, kidney allocation is based on geographical distance between donor and recipient.
Find more information about KAS here.
What impact do these changes have on the existing Pancreas Allocation System (PAS)?
PAS was implemented in 2014 and is still in effect. The changes impact match sequencing in PAS. Instead of relying on DSA and region, pancreas and kidney-pancreas allocation are based on geographical distance between donor and recipient.
Find more information about PAS here.
I’m an OPO professional—how can I learn about the modifications to released kidney and pancreas allocation?
There have been significant changes to the policies that determine the “backup” priority for these organs. New released organ allocation policies address the reallocation of kidney, kidney-pancreas, pancreas, and islets in situations in which an organ allocated to an original intended recipient is unable to be transplanted in that recipient.
For released kidneys, the major change is that the host OPO maintains responsibility for any necessary continued allocation either using the original match run or a new match run with a 250NM circle around the intended recipient hospital. The allocation of released kidneys is no longer being done at the importing OPO or DSA level. There are also changes to released kidney-pancreas, pancreas, and islets.
Professional education resources for OPO staff on these modifications to released organ allocation are available on UNOS Connect.
Find a summary of the policy changes and a visual aid to the reallocation processes in the new system on the policy’s toolkit page.
Why were DSA and region removed from kidney and pancreas allocation?
The new kidney and pancreas allocation system replaced a highly inconsistent set of local and regional boundaries historically used to allocate these organs with a consistent mechanism that treats transplant recipients equitably based on their transplant hospital’s distance from the donor. These improvements 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. The Final Rule requires that policies “shall not be based on the candidate’s place of residence or place of listing, except to the extent required” by the other requirements of the Rule. The changes mean that match sequencing is now based on geographical distance between donor and recipient instead of fixed DSA and regional boundaries. This ensures that the system is based appropriately on the medical needs of patients rather than artificial dictates of geography.
When were these policies approved?
After taking into consideration the feedback generated through two cycles of public comment, the Board approved removing DSA and region from kidney and pancreas at its December 2019 meeting. The additional policies addressing Alaska allocation, prioritization of medically urgent kidney candidates, and OPO processes related to reallocating released organs were approved at the Board’s June 2020 meeting.
How are offers being made in the new system?
In the new system, kidney and pancreas offers (except for rare, very well-matched donor and recipient combinations nationwide) are offered first to candidates listed at transplant hospitals within 250 NM of the donor hospital. Offers not accepted for any of these candidates are then made for candidates beyond the 250 NM distance. Kidney and pancreas candidates receive proximity points in the new system that prioritize them within their classification.
Find detailed information in the policy notices on the policy toolkit pages.
How do proximity points work in the new system?
A candidate’s proximity points are based on the distance between their transplant program and the donor hospital. Proximity points are intended to improve the efficiency of organ placement by adding priority for candidates closer to the donor hospital. Mandatory national shares still apply.
Learn more about proximity points on the policy’s toolkit page.
I am a transplant professional and have medically urgent candidates in my care. How does the new policy impact their prioritization?
This policy was developed because the policy to remove DSA and region from kidney allocation eliminated Policy 8.2.a: Exceptions Due to Medical Urgency. The OPTN Board of Directors approved this change in order to provide a consistent definition of medical urgency and also ensure medically urgent candidates receive allocation priority in the new system. Find details about the new medical urgency definition and classifications within all kidney allocation sequences in the policy notice. Find a summary of policy changes and policy documents on the policy toolkit page.
Professional education resources for both phases of implementation are available on UNOS Connect.
What professional education materials are available on UNOS Connect?
The following online educational modules are available on UNOS Connect:
- KID11: Modifications to Released Kidney and Pancreas Allocation
- KID112: Removing DSA and Region from Kidney and Pancreas Allocation
- KID113: Medical Urgency Data Collection Period (previously Phase 1)
- KID114: Medically Urgent Status for Adult and Pediatric Candidates (previously Phase 2)
- QLT102D: Notification Limits for Distance-based Allocation
- QLT103D: Acceptance Criteria for Distance-based Allocation
- Learn how your pancreas works and about a pancreas transplant operation
- Questions and answers for transplant candidates (PDF brochure)