Halpern Samantha E, Singh Ruby, Jawitz Oliver K, Gurses Ahmed, Alderete Isaac S, Klapper Jacob A, Nam Lucy, Hartwig Matthew G, Osho Asishana A, Patel Kunal J
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
JAMA Surg. 2025 Jul 9. doi: 10.1001/jamasurg.2025.2142.
Allocation out of sequence (AOOS) allows organ procurement organizations (OPOs) to offer organs outside of standard allocation and bypass those atop the match run. AOOS may allow OPOs to successfully place medically complex organs; however, increasing use of AOOS also raises concern for inefficiencies within the allocation process and may exacerbate systemic inequities.
To characterize patterns of lung AOOS among organ procurement organizations and transplant centers and compare lung transplant characteristics and outcomes between in-sequence and AOOS groups.
DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, the United Network for Organ Sharing registry was queried for lung transplants performed between September 1, 2021, and June 30, 2024. Data were linked to the Potential Transplant Recipient file to identify all offers for included donor lungs. These data were analyzed from October 2024 to February 2025. Participants included adult donors who donated at least 1 lung for transplant and corresponding primary isolated lung transplant recipients. The final cohort included 7914 lung donor-recipient pairs.
EXPOSURE(S): Lung AOOS vs in sequence, defined by match-run refusal codes for donor lung offers.
MAIN OUTCOME(S) AND MEASURE(S): Donor and recipient characteristics, posttransplant outcomes, and OPO-level and transplant center-level rates of lung AOOS.
Overall, 7914 lung transplants were included, of which 558 used AOOS (7.1%). Rates of lung AOOS ranged from 0% to 30% among OPOs and 0% to 50% among transplant centers. Use of lung AOOS increased in the continuous distribution era (10% vs 4%; P < .001). Donors of AOOS lungs were more likely to donate after circulatory death and had lower partial pressure of oxygen/fraction of inspired oxygen ratios, longer ischemic times, and longer travel distances. AOOS recipients were less likely to require pretransplant hospitalization, intensive care, and ventilator or extracorporeal membrane oxygenation support. On multivariable analysis, lung AOOS was associated with lower odds of prolonged intubation and early acute rejection and shorter posttransplant hospital length of stay.
AOOS is increasingly used in lung transplant and is associated with transplant of medically complex lungs into lower acuity recipients. Further investigation is needed to understand how AOOS affects lung utilization, especially in the era of continuous distribution.
顺序外分配（AOOS）允许器官获取组织（OPO）在标准分配之外提供器官，并绕过匹配队列中排在前列的患者。AOOS可能使OPO成功分配医学上复杂的器官；然而，AOOS使用的增加也引发了对分配过程效率低下的担忧，并可能加剧系统性不平等。
描述器官获取组织和移植中心之间肺AOOS的模式，并比较按顺序分配组和AOOS组之间的肺移植特征及结果。
设计、设置和参与者：在这项回顾性队列研究中，查询了器官共享联合网络登记处2021年9月1日至2024年6月30日期间进行的肺移植情况。数据与潜在移植受者档案相关联，以识别纳入的供体肺的所有供体情况。这些数据于2024年10月至2025年2月进行分析。参与者包括至少捐献1个肺用于移植的成年供体以及相应的初次孤立肺移植受者。最终队列包括7914对肺供体 - 受体。
根据供体肺供体情况的匹配队列拒绝代码定义的肺AOOS与按顺序分配。
供体和受体特征、移植后结局以及OPO层面和移植中心层面的肺AOOS发生率。
总体而言，共纳入7914例肺移植，其中558例采用了AOOS（7.1%）。OPO中肺AOOS的发生率在0%至30%之间，移植中心中在0%至50%之间。在连续分配时代，肺AOOS的使用有所增加（10%对4%；P <.001）。AOOS肺的供体更有可能在循环死亡后捐献，并且氧分压/吸入氧分数比值更低、缺血时间更长、运输距离更远。AOOS受者在移植前需要住院、重症监护以及使用呼吸机或体外膜肺氧合支持的可能性较小。在多变量分析中，肺AOOS与气管插管时间延长和早期急性排斥反应的几率较低以及移植后住院时间缩短相关。
AOOS在肺移植中的使用越来越多，并且与将医学上复杂的肺移植给病情较轻的受者相关。需要进一步研究以了解AOOS如何影响肺的利用，特别是在连续分配时代。
