Improving equity of access/transparency in organ allocation

PURPOSE OF REVIEW: Persistent inequities in lung transplant access arise from biologic constraints, geographic variation, and system-level practices that are not fully addressed by urgency-based allocation alone. The recent implementation of continuous distribution and the Composite Allocation Score (CAS) represent a major policy shift intended to improve fairness and transparency in lung allocation. This review examines whether early evidence supports these goals and identifies remaining challenges. RECENT FINDINGS: Early national and multicenter analyses demonstrate increased transplant rates and reduced waitlist mortality under CAS without compromise in short-term posttransplant survival. Continuous geographic scoring and biologic disadvantage adjustments appear to improve access for short-statured candidates, women, and some sensitized patients. However, disparities persist for blood group O recipients, highly sensitized candidates, and patients listed at centers with conservative acceptance practices. Increased travel distance and rising allocation out of sequence (AOOS) highlight emerging transparency and logistical concerns. SUMMARY: Continuous distribution represents a meaningful advance in equity and transparency in lung allocation, but allocation reform alone cannot eliminate disparities arising from biologic limitation, geographic variation, or center-level practices. Ongoing monitoring, policy refinement, and system-wide standardization are essential to ensure equitable and ethical use of donor lungs.