Unlocking the Full Potential of Organ Transplants

Addressing Organ Non-Use to Maximize the Gift of Life

At the core of the organ donation and transplant system is an ongoing challenge: The demand for organs far exceeds the available supply. Even though the U.S. continues to perform an increasing number of transplants each year, we still have more than 100,000 patients waiting for a life-saving organ. It begs the question: If our country is facing an organ shortage crisis, then why are donated organs going unused?

United Network for Organ Sharing (UNOS) and other groups have been diligently investigating the rising trend of organ non-use to identify root causes and develop effective solutions. As is the case with most elements of organ donation and transplant, the issue is complex and demands multi-faceted solutions from all stakeholders in the donation and transplant system.

As of March 2022, 25% of deceased donor kidneys recovered for transplant, were not ultimately transplanted.  Any organ not transplanted represents a loss, both for the selfless donor’s family and the waiting patient. We are called to honor the gift of life, and that commitment includes not only identifying the issue as to why this occurs, but also seeking substantive solutions to address it. We owe our patients and donor families nothing less.

To date, the most commonly reported reason for a donor organ to go unused is that the list of best-fit candidates on the waitlist was exhausted. In other words, every surgical team representing a patient declined the organ offer until there were no patients remaining on the list who were a match. Independent research suggests that registered transplant candidates who died in need of an organ had received a median of 16 organ offers while waitlisted.

Understanding Organ Non-Use

In order to fully grasp the complexities surrounding organ non-use, one must first understand the organ-matching process: Organ Procurement Organizations (OPOs) recover organs from deceased donors; UNOS, operating under contract with the federal government  in its role as the nation’s transplant system, matches them to the most compatible and medically urgent transplant candidates; the organs are then offered in descending order based on allocation rules to the hospital transplant programs where those candidates are registered. The decision to accept the organ offer ultimately rests with the matched candidates and their medical teams.

At UNOS, we have observed that the rate of organ non-use has been increasing for years, even as donation and transplant rates have also risen.

There are numerous reasons why some organs would be deemed medically unsuitable for transplantation to specific patients, such as organ biopsy findings that could lead to limited organ function or to complications post-surgery.  As a result, there is and will likely remain a degree of non-use based entirely on patient safety and anticipated outcomes. More than any other part of the transplant system, the medical teams at transplant programs have the most comprehensive understanding of their patients’ needs and what organs have the highest chances of resulting in successful transplants. They understand that no two organs are of equal quality. Organs from younger, healthier donors are much more likely to be accepted for transplant than organs recovered from donors who are older or who had health complications prior to their passing. Moreover, there have been annual increases in the successful recovery of organs from donors who experienced circulatory death rather than brain death (DCD donors).  Organs from these donors present greater challenges for successful use by medical teams accepting these organs for appropriate recipients.

These medically complex organs can often be used to save lives, but they nonetheless go unused. Despite this, recent medical innovations and practices have allowed more of these organs to be safely recovered, enabling more transplant surgeries to be performed every year. Although we have these enhanced capabilities thanks to many system-wide advancements, a non-use rate of zero would suggest that OPOs are either failing to recover or purposefully avoiding organs that may be more complex but remain perfectly safe for transplant.

Finding Solutions

Working in collaboration with members of the donation and transplantation community and experts in other fields, UNOS is pursuing a variety of innovative strategies to improve organ acceptance rates at hospitals – to get them to say “yes” on organ offers more easily. UNOS is doing this to save more lives both in its role as the nation’s transplant system – or Organ Procurement and Transplantation Network (OPTN) – and as the mission-driven nonprofit committed to continuously improving the system for the patients who rely on us.

This includes working to improve transportation options for donor organs, as every effort should be made to optimize their timely and efficient delivery.

A vital part of the solution is the need to streamline the acceptance of organ offers by transplant programs. A congressionally requested report by the National Academies of Sciences, Engineering, and Medicine (NASEM) emphasizes the importance of making it easier and quicker for transplant centers to accept to organ offers. In line with this goal, UNOS is leading OPTN collaborative efforts to enhance screening and offer processes for OPOs and transplant programs.

Other relevant UNOS and OPTN projects underway include:

  • Offer Filters, a multi-criteria data tool that provides insight to kidney transplant programs on their offer acceptance habits and allows them to filter out offers that they historically do not accept. Such offers could then be presented earlier to other centers who would be more willing to use those organs for transplant, thereby saving time in the offer process and lowering the risk of non-use. More than half of the kidney transplant centers in the nation have elected to use offer filters since UNOS introduced them in January 2022.
  • Predictive Analytics, another tool offered to kidney transplant programs that – at the time of an organ offer – leverages data and statistics-based modeling to predict when the transplant candidate in-question could receive the next organ offer as well as their likelihood of survival during that time without a transplant. During a pilot phase, participating programs showed a 2.9 percentage point increase in offer acceptance compared to the previous period while control centers did not show an increase.
  • A new image study viewer provides increased image quality in the national donor image sharing hub that enables healthcare providers to quickly access vital information about potential donors and make better informed decisions when considering organ offers.
  • A UNOS-developed travel application helps OPOs select the most efficient options for shipping organs on commercial flights. It aggregates real-time flight schedules, driving directions and critical logistics data like cargo hours to give pilot program users a comprehensive look at an organ’s projected travel time and path. The tool is expected to be available to all organ procurement organizations this year.   

Together, these innovations can be applied to the overall organ donation and transplant ecosystem to ensure that donor organs are being offered to the right transplant candidates at the right time.

Equally important to the sophisticated transplant tools are the professionals who use them. Ongoing collaborations within the organ donation and transplant community are underway to emphasize and encourage collective action. A national collaborative led by UNOS was initiated in January, uniting experts from more than 80 leading transplant programs across the country, with the specific goal of increasing organ offer acceptance rates. The goal of the collaborative is to share effective practices with the community and increase system efficiencies. The long-term results can help inform innovative solutions to organ non-use.  However, we must not become complacent: continued investment in research and education is essential to saving lives and honoring selfless donors and their families.

Forward Together

The issue of organ non-use demands immediate attention and united action. Each organ donation represents a precious opportunity to save a life, and it is a tragic loss when a donor’s generosity does not result in another life saved. The entire organ donation and transplant community must redouble our commitment to maximizing the gift of life. Collaboration among all stakeholders – including UNOS, OPOs, transplant programs, Congress and government regulators – is essential. We must continue to hold ourselves accountable, foster innovation, and strive to overcome challenges to arrive at a system that works better for every patient in need.

By embracing innovative solutions, such as leveraging new technology to improve organ offer processes, expanding the criteria for suitable organs, and enhancing allocation methods, we strive to unlock the full potential of organ transplantation. Further public education and awareness campaigns are vital to dispel myths, misconceptions, and stigmas surrounding transplantation and organ donation.

Together, we have the power to transform the lives of countless individuals awaiting a second chance. The time for action is now. Let us maximize the gift of life and bring hope to those in need.


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Dr. David Klassen
Dr. David Klassenhttps://unos.org/
Dr. David Klassen is the Chief Medical Officer of United Network for Organ Sharing (UNOS), the mission-driven non-profit leading the U.S. organ donation and transplantation system. Since joining the organization in 2014, Dr. Klassen has brought a vital clinical perspective to national transplant policymaking and patient safety efforts. Dr. Klassen earned his medical degree from the Ohio State University in Columbus and completed his internal medicine and nephrology training at Johns Hopkins Hospital in Baltimore, Maryland.
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