OPTN work groups propose audited ‘offer’ definition and expedited kidney pathway to reduce out‑of‑sequence allocations

Justin Wilkerson, lead for the allocation‑out‑of‑sequence (AOOS) work groups, told the OPTN board that the teams have drafted a plain‑language operational definition of an "organ offer" and several complementary projects intended to make offers auditable and reduce off‑system allocations.

Wilkerson read the draft definition as a "formal, verifiable communication from an OPO to a transplant hospital for one or more specific potential transplant recipients, indicating the availability of a specific organ in the allocation order specified on the match run," and said valid offers must be transmitted electronically through OPTN channels, time‑stamped and traceable. Under the draft, informal off‑system contacts such as unrecorded texts or phone calls would not meet the definition.

The work groups also proposed an expedited pathway for kidneys that are at heightened risk of non‑use. Kevin Lee, who led the expedited‑placement subgroup, described a draft eligibility approach that would trigger expedited handling after a combination of time and refusals (the presentation cited an illustrative threshold of about six hours of cold ischemic time and roughly 30 declines on a match run). Once in an expedited pathway, the proposal envisions a short, concurrent acceptance window during which multiple centers and patients would make decisions simultaneously so that an organ can be allocated more quickly and reduce the risk of discard.

A separate compliance project recommended establishing a board‑directed audit and mentorship capability to monitor member and OPO compliance, report metrics to leadership, and share best practices. Wilkerson said the intent is to combine data‑driven auditing with outreach so high‑performing OPOs can mentor peers and so that aggregate problems can be identified earlier.

All presenters emphasized that these are draft concepts. The leads told the board the concept papers have been submitted to board leadership, HRSA and the OPTN legal team; the proposals will be refined to ensure compliance with the National Organ Transplant Act and the Final Rule before any formal policy proposal or public comment period.

Board members asked technical and operational questions about the definitions and pilots — for example, whether labeling out‑of‑sequence communications as "non‑offers" would simply rebrand the same behavior and whether centers lacking surgical expertise for a particular complex organ could be excluded from enrolling in a concurrent‑clock pilot. Wilkerson and others said those issues are being considered and that pilots would be carefully scoped, including opt‑in criteria for centers and additional guardrails.

The board did not vote on any of the draft proposals. Wilkerson said the teams will pause further work while early legal and HRSA feedback is obtained, then resume with revisions and broader circulation for comment.