Recommendations for the United Network for Organ Sharing (UNOS) point system for donor kidney allocation

To: Margaret D. Allen, MD - President, UNOS
From: Thomas A Gonwa, MD, FACP - President, ASTP
Date: October 17, 1994

Date posted on the Web: July 25, 1996

Dear Dr. Allen:

The American Society of Transplant Physicians Scientific Studies Committee has evaluated the U.N.O.S. point system for donor kidney allocation. Their findings have been presented to the Executive Committee of the A.S.T.P. who wishes to make the following recommendations to U.N.O.S. point system.

The recommendations are as follows:

1. The system should be altered to alleviate inequities of the current system of cadaveric donor kidney allocation;
2. The altered point system for kidney allocation should be implemented as a single policy nationwide and managed at the local level;
3. Extra points should not be assigned on a racial basis;
4. More emphasis should be placed on waiting time. The current system provides one point for the patient with the longest waiting time and 1/2 point for each year on the waiting fist. This issue is very important to balance between the ethical principals of medical utility and justice. A new system is recommended whereby each month of waiting time constitutes 0.1.;
5. Eliminate points for the categories with poor matches because they are associated with actually lower ten year survivals then the overall group of transplant recipients. Thus, the following match category should be deleted from the point system.
   • 0 AB mismatch
   • 3 BDR mismatch
6. O ABOR mismatch category should be maintained as a mandatory share category. Before this is implemented careful study must take place to make sure that this is not further result in inequities of organ allocation to minority recipients.
7. The concept that permissible HLA mismatching criteria based on donor recipient sharing of CREGs and critical amino acid residues needs further study. This is promising and might lead to more equitable distributor of organs to minority recipients. The A.S.T.P. believes that this concept should be studied in depth to determine if it could improve organ allocation.
8. A similar concept of permissible HLA mismatch categories which insures optimal graft survivals and equitable organ allocation for all racial groups of transplant patients also deserves further study.

The A.S.T.P. Scientific Studies Committee is willing to participate in the formulation of a list of CREGs, the development of criteria for permissible HLA mismatching and their implementation in the U.N.O.S. point system for organ allocation. Please feel free to contact myself or Dr. Rene Duquesnoy, Chairman of the A.S.T.P. Scientific Studies Committee for further information. Dr. Duquesnoy's address is Univ of Pittsburgh Med. Ctr., Biomedical Science Tower, Rm W1552, Pittsburgh, PA 15261, and his telephone number is 412/624-1075.

Sincerely yours,

THOMAS A. GONWA, M.D., F.A.C.P., President

TAG/eg

cc: Douglas J. Norman, MD, President-Elect
Leslie Miller, MD, Secretary/Treasurer
Rene J. Duquesnoy, PhD

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