Equity Series Part 5: Barriers to Saying Yes to an Organ

November 10, 2023

The organ matching and offer process primarily looks at potential recipient and donor data to determine physical and immunogenic compatibility. However, additional factors are also at play in the process of saying yes to an organ. For example, individual transplant centers, hospitals, and even surgeons have varying risk tolerances for accepting organs. Some centers have a policy of not accepting Hepatitis C positive (HCV-positive) donor organs. Other times, individual surgeons may not accept HCV-positive donor organs.

A close look at frailty

Some of these factors can also impact equity. Research shows that medical assessment factors such as frailty of recipients might create inequities. Frailty refers to impaired functional capacity, physiological reserve, and body resilience. These impairments can impact the success of major surgeries such as transplantation and lead to prolonged recovery and increased complications, including sub-optimal graft function. 

Frailty is generally associated with older patients, although not all older patients are frail. However, lack of standardization in tools and approaches to measure and evaluate frailty is needed to ensure older patients are not treated unfairly and perceived as frail, despite their functional health. IIf older patients are characterized as frail, they may have organs declined on their behalf by their transplant team. 

How can the transplant system support patients who meet an evidence-based standard for frailty? Some data suggests that frailty is a more important measure for patients who are low-risk, rather than high risk (i.e., with multiple comorbidities). Recent research also indicates that adequate preventative measures can modify the risk associated with frailty. Canadian Anaesthetist Franco Carli's research team developed a protocol to improve functional status prior to surgery in order to modify the post-surgical decline. Additionally, patients are also treated according to an enhanced recovery after surgery. Such measures could greatly impact the functional characteristics associated with frailty and reduce the risk of a transplant.

Systemic problems that lower acceptance rates

Organ non-use is a broader, systemic problem in many transplant systems. Research suggests that it is possible that some transplant providers are rejecting reasonable organ offers due to a reluctance to perform riskier surgeries more broadly. Riskier surgeries means for both medically complex organs, or for recipients with challenging co-morbidities (which can include very advanced age). While the surgery might be in the interest of the patient, the risk profile could result in damage to a transplant center's statistics in places like the United States. Variation in offer acceptance rates of transplant programs can mean acceptance rates are 80% lower than expected, while other programs accept at rates 3.5 to 6 times the expected rate. This distribution is seen as inequitable and a better understanding of why offer acceptance rates are so low at some centers is needed to improve transparency and equity.

Recommended changes to improve the offer acceptance process include increasing transparency on the rules, exclusions, and filters used by different transplant centers. This could enable patients to recognize which centers make decisions in alignment with that patient's needs.


McAdams-DeMarco; AST Kidney Pancreas Community of Practice Workgroup. Perceptions and Practices Regarding Frailty in Kidney Transplantation: Results of a National Survey. Transplantation. 2020 Feb;104(2):349-356. doi: 10.1097/TP.0000000000002779. PMID: 31343576; PMCID: PMC6834867.

Weimann A, Ahlert M, Seehofer D, Zieschang T and Schweda M (2023) Old Age and Frailty in Deceased Organ Transplantation and Allocation–A Plea for Geriatric Assessment and Prehabilitation. TransplInt 36:11296.doi: 10.3389/ti.2023.11296

National Academies of Sciences, Engineering, and Medicine. 2022. Realizing the Promise of Equity in the Organ Transplantation System. Washington, DC: The National Academies Press. https://doi.org/10.17226/26364.

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