• Posted June 12, 2023

Many Hospitals Ignore Directives of Organ Transplant Waiting Lists: Study

Many transplant centers routinely practice “list-diving,” when the top candidate among potential organ recipients is skipped in favor of someone further down the list, new research shows.

The top candidate is ranked that way based on an objective algorithm using age, waiting time and other factors, while choosing someone else happens with little oversight or transparency. And that may harm some patients and can lead to disparities and even discarding donor organs, the study authors said.

“It's an open secret that some transplant centers regularly apply their own criteria for matching donor kidneys to eligible patients,” said study leader Dr. Sumit Mohan, a kidney transplant physician and associate professor of medicine at Columbia University Vagelos College of Physicians and Surgeons in New York City. “But no one has examined if this practice is widespread.”

For the new study, the researchers analyzed approximately 6,000 transplant candidates and 4,700 transplants at 11 centers between 2015 and 2019. Each of these centers was geographically isolated, so they could decline the offer of a kidney without losing it to another center, but still accept it for a lower-priority patient.

About 68% of kidneys offered to these centers were not placed with the top-ranked candidates on the waiting list. Reasons cited typically were concerns about organ quality.

It may be that centers declined the offer for their top-ranked patient believing that they were likely to receive a better quality organ soon. Accepting a lower-quality organ for a lower-priority patient would be offset by the quicker timeline.

“For example, if you have a 25-year-old at the top of the list and the center is offered a kidney from a 75-year-old donor, the center might decline that offer, believing it's better suited for an older candidate lower down on the list,” Mohan said in a university news release.

Yet, this study found that only 44% of the highest-quality kidneys were given to the highest-ranked candidates.

“It seems that transplant centers often overlook their top candidates and there are many organ declines that we don't have a good explanation for,” Mohan reported.

The study authors noted several issues with this practice of list diving, including that patients could die while remaining on the waiting list or deteriorate to the point they need to be de-listed.

Declined offers also add to the time that an organ is kept on ice, compromising its viability. A total of one in four donated kidneys are discarded, despite transplantation being the most cost-effective therapy for end-stage kidney disease, the researchers noted.

Patients also rarely have a say in whether to decline the organ.

“Patients are rarely involved in the decision-making process and transplant centers do not currently inform patients when an organ offer is declined on their behalf,” Mohan said. “We should give patients more say in the process and have them participate in shared decision-making.”

Other studies have found that organ declines can be subjective and based on the recipient's race and other factors, such as obesity.

The investigators said the system could benefit from improving algorithms to more precisely match specific organs to recipients.

“All told, list diving undermines the intended objective design of the allocation system in a manner that is shrouded from both patients and regulatory oversight,” Mohan said. “And it risks undermining the trust that patients and donor families have in a fair and equitable system.”

The research was supported by grants from the U.S. National Institutes of Health and the Nelson Family Faculty Development Awards.

The report was published online June 5 in JAMA Network Open.

More information

The U.S. National Library of Medicine has more on organ donation.

SOURCE: Columbia University Irving Medical Center, news release, June 8, 2023