Update on Lung Continuous Distribution Policy

Marci Gleicher
State of Residence: Florida

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because ,as a Psychiatric Nurse Practitioner, I see firsthand how a patient's clinical trajectory is inseparable from their mental health. Waiting for a transplant is already one of the most psychologically taxing experiences a patient and their family can face, and I have witnessed how a decision as consequential as a sudden shift in one's place on the waiting list can compound that distress, introducing new anxiety, hopelessness, and a sense of instability at a time when patients most need to trust that the system guiding their care is fair and grounded in sound medical judgment. Mental health is not separate from transplant outcomes; it directly affects a patient's ability to cope with their illness and engage with their care.

Beyond my clinical specialty, I hold a deep commitment to evidence-based decision-making in every area of medicine. Decisions with life-and-death consequences, such as where someone falls on a transplant waiting list, must be grounded in rigorous data and clear evidence that they will reduce, not increase, mortality. When a policy change of this magnitude is made without that evidentiary foundation, it undermines both patient outcomes and patient trust, and it is that combination, the psychological toll on patients and the abandonment of evidence-based practice, that compels me to ask the Board to reverse this decision.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,

Marci Gleicher

Suzanne Brennan
State of Residence: Minnesota

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I do not agree with the changes made to how lungs are allocated to the patient/people who desperately need them. I got my lungs under the LAS method before that changed and know quite a number of people who got theirs under the CAS when it was introduced.

As I understand it, the new methodology uses something different altogether which will primarily be related proximity. Coming from the Midwest, I am concerned that the people in our region are less likely to get lungs as quickly as before.

Last, I don’t like that the decision method was not decided with input from true experts in the process. Please go back to the way it was with CAS.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Suzanne Brennan

Nearly 30 years ago, organ donation saved my life through a double lung transplant. Today, I am waiting for a kidney transplant. Having experienced transplantation from both sides—as a recipient and now as a transplant candidate once again—I know that organ allocation policies determine who gets the chance to live.

I am deeply concerned that this significant policy change moved forward despite the unanimous opposition of the Lung Committee and the concerns raised by lung transplant experts. Changes with the potential to affect patient survival should be supported by strong clinical evidence, a transparent process, and meaningful input from the experts who care for these patients every day.

I support improving efficiency and reducing organ waste, but medical necessity and patient outcomes should remain the highest priority in every allocation decision. I respectfully ask HRSA and the OPTN Board to restore the previous CAS point allocation and continue to put patients first.

Lee D Keddie

State of Residence: Washington

Relationship to lung transplantation: Organ Donation & Transplant Community Vendor Executive

Re: Public Comment on Update to Lung Continuous Distribution Policy

Dear OPTN Board of Directors, HRSA, and members of the Lung Transplantation Committee:

Thank you for the opportunity to comment on the proposed update to the Lung Continuous Distribution policy. I appreciate the difficult work involved in balancing medical urgency, post-transplant outcomes, biological disadvantages, patient access, placement efficiency, and system compliance. I also recognize that the specific proposal under public comment is primarily directed at allocation out of sequence, logistical complexity, and placement efficiency, and that the proposed change proportionally reduces—not increases—the points assigned to the height component of the Composite Allocation Score.

My comment is focused on a related issue that this proposal highlights: the continued use of candidate height as a stand-alone biological-disadvantage allocation factor intended to approximate access to size-compatible donor lungs.
Under both the current and proposed scoring structure, height remains a distinct component of Candidate Biology, alongside ABO and CPRA. As I understand the policy, each lung candidate receives height points based on the proportion of donors the candidate is expected to be able to accept based on height compatibility. I understand the purpose of this approach: candidates who truly have fewer size-compatible donor options should not be disadvantaged in allocation. That is an appropriate and important policy goal, and I recognize that the current height-based approach reflects a meaningful historical evidence base.

My comment is not intended to suggest that size-related biological disadvantage should be deemphasized. To the contrary, size compatibility is clinically important in lung transplantation. My concern is simply that advances in imaging, available clinical data, and data infrastructure may create an opportunity to evaluate whether height remains the best available surrogate measure for that purpose.

Height can be a useful proxy, or surrogate measure, for what may be true across a population. It may indicate that some candidates are more likely to have limited access to size-compatible donor lungs. But a proxy is still an indication of what might be true; it is not the same as measuring what is true for a specific candidate’s anatomy and a specific donor lung or lung pair. Where more direct anatomic information is available, it may provide a more anatomically specific assessment of donor-recipient size compatibility than overall body height alone.

The clinical question is not simply the candidate’s height in isolation. The clinical question is whether a given donor lung, or donor lung pair, is anatomically suitable for a given recipient. Human body proportions vary substantially. Two individuals of the same height can have different thoracic dimensions. A shorter candidate may have lung or thoracic dimensions compatible with a broader donor pool than height alone would suggest. Conversely, a taller candidate may have thoracic or lung-size requirements that are more restrictive than height alone would suggest. Non-standard anthropometrics, including amputations, skeletal deformity, or unusual body proportions, further illustrate why overall height may not always reflect the actual anatomic dimensions relevant to lung size matching.

In contemporary clinical practice, donor lung offers are evaluated with imaging and clinical data. Basic lung or thoracic dimensions may be obtainable from routine chest imaging, and where CT imaging is available, more precise dimensions or volumetric assessment may be possible. Even a simple, standardized measurement—such as donor lung length or another clinically validated lung or thoracic dimension, paired with a candidate-specific anatomic parameter or acceptable size range—could be evaluated alongside the existing height-based model.

Importantly, this would not require discarding height data or disregarding the historical evidence base that used height as the known surrogate. Donor and candidate height could continue to be collected and retained for analytic continuity, validation, quality monitoring, and comparison with prior studies. The question is not whether height has been useful. The question is whether additional direct anatomic measurements could further improve precision, equity, allocation efficiency, offer acceptance, organ utilization, and post-transplant outcomes.

I respectfully suggest that HRSA, OPTN, the Lung Transplantation Committee, SRTR, and the clinical experts who have developed and maintained the lung allocation framework consider this as an opportunity for future study. One possible approach would be to begin with standardized data collection before making any change to the score itself. For example, OPTN could consider evaluating whether a simple, reproducible lung or thoracic measurement from routine donor imaging, paired with candidate-specific anatomic compatibility information, improves predictive accuracy when compared with height-based compatibility.

Such an evaluation could be conducted in a way that preserves continuity and avoids unintended disruption. Height could remain available as the current evidence-supported surrogate and as a fallback when standardized anatomic measurements are unavailable, incomplete, or not yet validated. Any future refinement should be evidence-driven and pursued only if modeling demonstrates improvements in equity, allocation efficiency, offer acceptance, utilization, and post-transplant outcomes without introducing unintended consequences.

This framing is consistent with the broader goals of OPTN modernization: better data, transparent evaluation, improved system performance, and fair allocation. It also preserves the important policy goal of protecting candidates who truly have fewer size-compatible donor options, while creating an opportunity to evaluate whether those candidates can be identified with greater anatomic precision.

I recognize that this issue may be outside the immediate scope of the current policy action, and I am not requesting that the Board resolve it within this proposal. I respectfully ask HRSA and OPTN to consider whether the continued use of height as the operative surrogate for lung size compatibility warrants further study, and whether future data collection and modeling could determine if direct anatomic measurements would strengthen the lung allocation framework.

Thank you for your consideration and for your work to improve the lung transplant allocation system.

Sincerely,
Lee Keddie

Lee Kedd

State of Residence: Washington

Relationship to lung transplantation: Organ Donation & Transplant Community Vendor Executive

Re: Public Comment on Update to Lung Continuous Distribution Policy

Dear OPTN Board of Directors, HRSA, and members of the Lung Transplantation Committee:
Thank you for the opportunity to comment on the proposed update to the Lung Continuous Distribution policy. I appreciate the difficult work involved in balancing medical urgency, post-transplant outcomes, biological disadvantages, patient access, placement efficiency, and system compliance. I also recognize that the specific proposal under public comment is primarily directed at allocation out of sequence, logistical complexity, and placement efficiency, and that the proposed change proportionally reduces—not increases—the points assigned to the height component of the Composite Allocation Score.

My comment is focused on a related issue that this proposal highlights: the continued use of candidate height as a stand-alone biological-disadvantage allocation factor intended to approximate access to size-compatible donor lungs.
Under both the current and proposed scoring structure, height remains a distinct component of Candidate Biology, alongside ABO and CPRA. As I understand the policy, each lung candidate receives height points based on the proportion of donors the candidate is expected to be able to accept based on height compatibility. I understand the purpose of this approach: candidates who truly have fewer size-compatible donor options should not be disadvantaged in allocation. That is an appropriate and important policy goal, and I recognize that the current height-based approach reflects a meaningful historical evidence base.

My comment is not intended to suggest that size-related biological disadvantage should be deemphasized. To the contrary, size compatibility is clinically important in lung transplantation. My concern is simply that advances in imaging, available clinical data, and data infrastructure may create an opportunity to evaluate whether height remains the best available surrogate measure for that purpose.

Height can be a useful proxy, or surrogate measure, for what may be true across a population. It may indicate that some candidates are more likely to have limited access to size-compatible donor lungs. But a proxy is still an indication of what might be true; it is not the same as measuring what is true for a specific candidate’s anatomy and a specific donor lung or lung pair. Where more direct anatomic information is available, it may provide a more anatomically specific assessment of donor-recipient size compatibility than overall body height alone.

The clinical question is not simply the candidate’s height in isolation. The clinical question is whether a given donor lung, or donor lung pair, is anatomically suitable for a given recipient. Human body proportions vary substantially. Two individuals of the same height can have different thoracic dimensions. A shorter candidate may have lung or thoracic dimensions compatible with a broader donor pool than height alone would suggest. Conversely, a taller candidate may have thoracic or lung-size requirements that are more restrictive than height alone would suggest. Non-standard anthropometrics, including amputations, skeletal deformity, or unusual body proportions, further illustrate why overall height may not always reflect the actual anatomic dimensions relevant to lung size matching.

In contemporary clinical practice, donor lung offers are evaluated with imaging and clinical data. Basic lung or thoracic dimensions may be obtainable from routine chest imaging, and where CT imaging is available, more precise dimensions or volumetric assessment may be possible. Even a simple, standardized measurement—such as donor lung length or another clinically validated lung or thoracic dimension, paired with a candidate-specific anatomic parameter or acceptable size range—could be evaluated alongside the existing height-based model.

Importantly, this would not require discarding height data or disregarding the historical evidence base that used height as the known surrogate. Donor and candidate height could continue to be collected and retained for analytic continuity, validation, quality monitoring, and comparison with prior studies. The question is not whether height has been useful. The question is whether additional direct anatomic measurements could further improve precision, equity, allocation efficiency, offer acceptance, organ utilization, and post-transplant outcomes.

I respectfully suggest that HRSA, OPTN, the Lung Transplantation Committee, SRTR, and the clinical experts who have developed and maintained the lung allocation framework consider this as an opportunity for future study. One possible approach would be to begin with standardized data collection before making any change to the score itself. For example, OPTN could consider evaluating whether a simple, reproducible lung or thoracic measurement from routine donor imaging, paired with candidate-specific anatomic compatibility information, improves predictive accuracy when compared with height-based compatibility.

Such an evaluation could be conducted in a way that preserves continuity and avoids unintended disruption. Height could remain available as the current evidence-supported surrogate and as a fallback when standardized anatomic measurements are unavailable, incomplete, or not yet validated. Any future refinement should be evidence-driven and pursued only if modeling demonstrates improvements in equity, allocation efficiency, offer acceptance, utilization, and post-transplant outcomes without introducing unintended consequences.

This framing is consistent with the broader goals of OPTN modernization: better data, transparent evaluation, improved system performance, and fair allocation. It also preserves the important policy goal of protecting candidates who truly have fewer size-compatible donor options, while creating an opportunity to evaluate whether those candidates can be identified with greater anatomic precision.

I recognize that this issue may be outside the immediate scope of the current policy action, and I am not requesting that the Board resolve it within this proposal. I respectfully ask HRSA and OPTN to consider whether the continued use of height as the operative surrogate for lung size compatibility warrants further study, and whether future data collection and modeling could determine if direct anatomic measurements would strengthen the lung allocation framework.

Thank you for your consideration and for your work to improve the lung transplant allocation system.

Sincerely,
Lee Keddie