OPTN Memo Linked to Fewer Kidney Transplants, Recovery Rates

A recent analysis suggests an allocation memorandum issued by the Organ Procurement and Transplantation Network (OPTN) last year may have contributed to a decrease in kidney recovery and transplantation rates, even as the proportion of unused kidneys declined. The findings, published in the Journal of the American Society of Nephrology, raise questions about the balance between equitable organ allocation and maximizing the number of transplants performed.

The OPTN memorandum, sent in August 2025, expressed concerns about potential disciplinary action for organ procurement organizations (OPOs) engaging in “out-of-sequence” (AOOS) kidney allocations – offering organs to transplant centers further down the list willing to accept them. While AOOS has historically been used to salvage kidneys that might otherwise travel unused, the OPTN signaled a preference for adhering strictly to the standard allocation algorithm. Researchers, led by Syed A. Husain, MD, MPH, of NYU Grossman School of Medicine, investigated whether this guidance had unintended consequences.

Understanding Kidney Allocation and the Role of AOOS

The process of matching deceased donor kidneys to potential recipients is complex, governed by a scoring system that prioritizes factors like blood type, tissue compatibility and waiting time. However, some kidneys are considered “difficult to place” due to characteristics like older donor age, longer cold ischemia time (the time the kidney is outside the body), or recipient antibody levels. AOOS allows OPOs to offer these kidneys to centers willing to accept them, potentially preventing them from being discarded. Previous research has shown mixed results regarding the effectiveness of AOOS in reducing nonuse rates.

Study Findings: A Dip in Recovery and Transplantation

The researchers analyzed OPTN data from three periods: August 6, 2025, to September 23, 2025 (the policy period after the memorandum). January 1, 2025, to August 5, 2025 (the same-year reference period); and August 6, 2024, to September 23, 2024 (the prior-year reference period). They compared kidney recovery, transplantation, and nonuse rates across these intervals.

The data revealed a statistically significant decrease in both kidney recovery and transplantation rates during the policy period. Specifically, the number of kidneys recovered per day fell from an average of 85.2 in the same-year period to 76.4 per day after the memorandum was issued. Similarly, the number of transplants performed daily decreased from 61.8 to 57.4. Annually, this translates to roughly 1,500 fewer transplants.

Interestingly, the proportion of unused kidneys actually decreased during the policy period (25% vs. 28% in the reference periods). This suggests that while fewer kidneys were being recovered and transplanted, OPOs were less likely to discard organs. The proportion of AOOS also decreased, from 24% in the same-year period to 15% after the memorandum.

Interpreting the Results: A Complex Picture

The study authors hypothesize that the OPTN memorandum may have led OPOs to be more cautious about initiating AOOS, fearing potential repercussions. This, in turn, could have resulted in fewer kidneys being recovered as OPOs may have refrained from pursuing organs they anticipated would require out-of-sequence allocation. The decrease in nonuse rates, despite the lower recovery and transplant numbers, suggests that OPOs may have been more selective in which kidneys they recovered, focusing on those more likely to be readily accepted by transplant centers.

However, it’s crucial to acknowledge the study’s limitations. The policy period was relatively short, and other events, such as a hearing by the U.S. House Committee on Energy and Commerce Subcommittee on Oversight and Investigations, may have also influenced organ donation and transplantation rates during this time. Ongoing efforts to reform the US organ donation and transplant system add further complexity to the analysis.

What Does This Mean for Patients?

The findings highlight the delicate balance between ensuring equitable access to transplantation and maximizing the utilization of available organs. While AOOS can be a valuable tool for salvaging difficult-to-place kidneys, concerns about fairness and transparency remain. The study suggests that discouraging AOOS without addressing underlying barriers to organ placement – such as logistical challenges or center preferences – may inadvertently reduce the overall number of transplants performed.

The researchers emphasize that nonuse rate alone may not be a reliable indicator of a policy’s effectiveness. A more comprehensive assessment should consider transplant volume and the potential impact on access to transplantation for all patients. Further research is needed to fully understand the long-term consequences of the OPTN memorandum and to identify strategies for optimizing kidney allocation.

The Path Forward: Ongoing Evaluation and Refinement

The OPTN continuously monitors the transplant system and makes adjustments to policies based on data and feedback from stakeholders. The agency is likely to review the findings of this study and consider whether further modifications to the allocation system are warranted. This may involve exploring ways to encourage appropriate use of AOOS while maintaining transparency and accountability. Ongoing evaluation of allocation policies is essential to ensure that the system remains responsive to the needs of patients awaiting transplantation.

For individuals on the kidney transplant waiting list, it’s important to maintain regular communication with their transplant center and stay informed about any changes to the allocation system. Patients should also discuss their individual risk factors and preferences with their healthcare team to make informed decisions about their care.