Home / The Science / HRSA’s Heavy-Handed “Out-of-Sequence” Organ Allocation Policy Slows Donation and Transplant Rates, Studies Show

HRSA’s Heavy-Handed “Out-of-Sequence” Organ Allocation Policy Slows Donation and Transplant Rates, Studies Show

Last year’s New York Times investigation portrayed “allocation out of sequence” (AOOS)—offering organs outside the standard computer-generated match list—as a sign that the transplant system is being rigged. Federal authorities responded, issuing a memorandum letting Organ Procurement Organizations (OPOs) and others in the transplant community know that AOOS was unfair and would no longer be tolerated, and that each time it was used, unwelcome scrutiny would follow.

However, new research suggests the Health Resources and Services Administration (HRSA)’s reaction to media pressure is having unintended and unwelcome consequences for an agency that has promised its reforms will increase the number of kidney transplants. Two recent studies examining what happened after HRSA restricted AOOS beginning in August 2025 found that the decline in AOOS was associated with fewer kidneys being recovered.

AOOS occurs when a donated organ is offered, accepted, or transplanted outside the order generated by the national computerized match run that ranks transplant candidates. Clinicians with Organ Procurement Organizations (OPOs) typically use AOOS to prevent donated organs that are rejected repeatedly by transplant surgeons from going to waste.

Some organs, especially kidneys from older and sicker donors, are difficult to match quickly enough through the standard sequencing. These organs can be life-savers for older patients  and those being treated at transplant centers willing to work with a wider quality range of organs. But the Times’ coverage depicted OPO officials as “leapfrogging over hundreds or even thousands of people when they give out kidneys, livers, lungs and hearts” in characterizing AOOS as a scandal.

In response to media pressure, under the leadership of Organ Transplant Branch Chief Dr. Raymond Lynch, HRSA announced in August 2025 the launch of a public “surveillance tool,” and instructed the Organ Procurement and Transplantation Network (OPTN) to send transplant centers and OPOs a memo warning that placing kidneys with transplant patients outside the official match sequence could trigger compliance scrutiny and punitive measures. After these measures were taken, data showed abrupt drops in AOOS, kidney recovery and kidney transplantation rates, according to the researchers.

Unintended Consequences

Two recent peer-reviewed studies—one based on national transplant registry data and another on a real-world operational test—both found that limiting allocation out of sequence can reduce the number of kidneys transplanted.

A national analysis published in the Journal of the American Society of Nephrologylast December examined OPTN data before and after the August 2025 memorandum. The researchers found that kidney recovery fell from about 85 to 76 organs per day after the memo, while daily kidney transplants dropped from roughly 62 to 57. Importantly, the study found that kidney discard rates did not increase—indicating the decline occurred because fewer kidneys were recovered in the first place. Researchers concluded that OPO clinicians may have responded to the disincentive of stricter oversight by not recovering kidneys they believed would be difficult to place.

If those rates were sustained, the study’s authors projected 1,500 fewer transplants annually. “Discouraging all AOOS without addressing barriers to placement efficiency…may decrease transplant access by removing an important tool to salvage nonideal organs,” they wrote.

A separate study forthcoming in the American Journal of Transplantation (AJT) examined what happened when one OPO, New England Donor Services, temporarily eliminated AOOS entirely for 30 days. During the study period, kidney nonuse rose sharply—from about 29 percent to more than 43 percent—even though donor volume and organ quality were similar to prior months. The discarded kidneys were disproportionately those considered harder to place.

The authors of the AJT study emphasize that their findings shouldn’t be interpreted as endorsing routine use of AOOS. Prior research has found that routine AOOS is not associated with improved kidney utilization and may exacerbate inequities in access to transplantation. Instead, the study examined the opposite extreme: what happens when AOOS is eliminated entirely. In that scenario, the researchers found, kidney nonuse rose sharply. This suggests that while routine AOOS raises legitimate concerns, eliminating all flexibility in organ placement will reduce the number of kidneys transplanted.

Equity vs. Utility

The debate over AOOS is also part of a broader tension within transplant policy between equity—strictly following the computer-generated waiting list—and utility, the goal of maximizing the number of lives saved. Federal regulators have increasingly framed AOOS primarily as a fairness issue, emphasizing adherence to the match run. But the science of transplant medicine has long required balancing the principles of equity and utility. Strict sequencing may appear equitable on paper, yet it can make it harder to place medically complex organs that are frequently declined by multiple programs. When those organs ultimately go unused, the result serves neither equity nor utility.

The challenge is compounded by structural realities within the transplant system. Transplant centers vary widely in their willingness to accept higher-risk organs, in part because their performance is judged heavily on one-year patient and graft survival. As a result, some centers routinely decline organs that other programs would transplant successfully. Time runs out for too many usable kidneys when they are repeatedly declined by more cautious transplant centers that happen to be next in line. The system needs mechanisms that quickly match difficult-to-place organs with the centers most likely to use them. Providing flexibility in placement with carefully used AOOS is a practical way to connect usable organs with patients who can benefit.

Many experts argue that the solution is not to eliminate flexibility but to better align incentives and transparency across the system. Policies that incorporate transplant center acceptance behavior and create more dynamic allocation tools could help ensure that hard-to-place organs reach the programs most willing to use them. The goal should be to improve both fairness and organ utilization—because no allocation system is equitable when a usable organ is ultimately discarded.

This debate is occurring within a transplant community that has changed the science of organ transplantation over the past decade. Advances in donor management, organ preservation and transplant practice have allowed clinicians to recover and save lives with kidneys that might previously have been discarded. But because not every transplant center has embraced these scientific advances, the system needs a mechanism to enable OPOs to send hard-to-place organs to the centers that are more likely to use them without risking regulatory penalties.

The federal government must relearn trust in the transplant community, including OPOs. As the US transplant system works to place a broader range of kidneys in a broader range of patients, the logistical challenge of matching organs quickly and effectively across hundreds of transplant centers has grown—helping explain why questions about flexibility in the allocation process have become more salient. New federal regulations should be aimed at clearing obstacles that prevent more life-saving gifts, not building barriers.

Taken together, the two studies point to the same conclusion: Fewer lives will be saved if OPOs and transplant surgeons are discouraged from accepting medically complex organ donations. HRSA’s leadership acted hastily and was too quick to concede to a media depiction of OPOs that focused on shock value but left out the science. The evidence suggests that limiting flexibility in organ placement risks producing the very outcome policymakers say they want to avoid; fewer transplants and more wasted organs. To quote the AJT study’s headline, “There is nothing equitable about a wasted organ.”