While about one third of Americans know someone who has had an organ transplant, the system that organizes the donation and transplantation process remains a mystery to most.
Organ transplantation is a measure of incredible scientific achievement. It began in earnest in the 1950s, with Dr. Joseph Murray performing the world’s first human kidney transplant in Boston. (He later went on to win the Nobel Prize for his work.) The world’s first kidney-pancreas, liver, and heart transplants followed in the late 1960s, along with breakthroughs in immunosuppression in the 1970s, necessary for successful transplantation.
Governing laws
As science advanced, more patients became eligible for transplants, and more donors became available to provide them. But the system matching one to the other was piecemeal.
For decades, a small and scattered group of local transplant hospitals managed organ procurement and transplantation themselves. A national, connected network didn’t exist.
That all changed in 1984 with the passage of the National Organ Transplant Act. The landmark law created today’s Organ Procurement and Transplantation Network (the network), a national matching system that fixed a fragmented, inefficient operation.
With the creation of the network, geographically diverse hospitals could communicate with others in the network, making transplantation quicker and more efficient. It also allowed for cross-country transplantation instead of limiting a donated organ to its immediate locale.
Notably, the law also stipulated that only one private organization would be contracted to run the entire network. The United Network for Organ Sharing (UNOS) won that federal contract in 1986 and has run the network ever since.
While delegating network operations to one organization seemed efficient at first, UNOS has garnered some valid criticism during its 40-year reign, including complaints about its antiquated technology and operational failures resulting in discarded organs.
A new law passed in 2023 addressed this by breaking up UNOS’ monopoly over the network and allowing the federal government to contract with multiple organizations at once to run it. These contract changes are still in the works.
Registry
The network uses a national registry to match deceased and living donors to recipients. This registry contains important details about both parties, including blood type, body size, and demographics.
When an organ becomes available, algorithms use all of those details to generate a list of eligible recipients, ranked by a composite score. Importantly, recipients aren’t simply ranked based on when they got on the waiting list. Instead, the registry is a “dynamic, ever-changing pool of information.” The organ is then offered to the top eligible recipient on the list and, if declined by the patient’s surgical team, is offered to the next person. (An organ may be declined due to a size mismatch or the recipient being temporarily unsuitable for transplant, among other reasons.)
Procurement and Transplantation
While UNOS oversees the entire national transplantation network, much of the work is coordinated by local organ procurement organizations.
Once a local organ procurement organization learns that an organ is available in its catchment area, it coordinates procurement from the donor and arranges transportation via ambulance, private courier service, or even commercial flight.
While most organs are delivered successfully, some organs are delayed in transit, lose viability, and have to be thrown away. Some just get lost, too.
Once received by the recipient’s surgical team, they work against the clock to transplant the organ. Through special preservation methods, organs can survive outside of the body for varying amounts of time. For example, kidneys can last up to 48 hours, while hearts and lungs can only survive four to six hours.
After surgery, the recipient maintains a lifelong regimen of immunosuppressant drugs and other treatments to prevent their body from rejecting the new organ. The network tracks outcome measures for successful transplantation, including recipient mortality and the transplant organ’s survival and functionality.
Organ donation has seen truly amazing innovation in the last 75 years. The United States’ network alone has saved hundreds of thousands of lives. Even though it is undergoing an operational makeover to improve efficiency and transparency, the network has proven its value and made good on Congress’ 1984 promise to streamline organ donation.
