The machinery that turns a tragedy into a transplant is quietly breaking down under its own success. A new review by transplant surgeons Christina M. Fleischer and Kyle H. Sheetz of Michigan Medicine, published in Current Transplantation Reports, argues that the American system for recovering organs from deceased donors has been transformed so rapidly, and on so many fronts at once, that it now faces unprecedented logistical complexity and rapidly escalating costs. The donor pool has changed shape, the technology used to keep organs alive outside the body has become far more expensive, federal regulators have redrawn the map of who gets which organ, and the reimbursement rules that pay for all of it have barely moved. The authors’ conclusion is provocative: rather than patching the existing pipeline, the United States may need to deliberately take it apart and rebuild it, potentially separating organ procurement, preservation, and transport into distinct, specialized operations.
The most fundamental shift is in who the donors are. For decades, the typical deceased donor was a young person declared dead by neurological criteria, a donation after brain death, or DBD, donor whose heart was still beating and whose organs could be recovered in a relatively controlled operating room environment. That profile has eroded. Driven partly by the decline of the drug overdose epidemic that had supplied a tragic stream of young donors, and partly by the deliberate expansion of eligibility criteria, donation has shifted toward older, medically complex individuals. In parallel, donation after circulatory death, or DCD, has grown dramatically. In DCD, death is declared after the heart stops, which means the organs endure a period of warm ischemia, deprived of oxygenated blood at body temperature, before recovery begins. That physiological insult makes DCD organs riskier to use and far more demanding to preserve, but the review notes that DCD has become an increasingly dominant share of deceased donation in the United States.
This changing donor phenotype collides with a stubborn biological constraint: ischemic time, the interval during which an organ sits without adequate blood flow between recovery and transplantation. Every hour of cold ischemia, the period when an organ is flushed with cold preservation solution and stored on ice, inflicts cumulative injury on delicate tissue such as the cells lining blood vessels and the energy-hungry mitochondria of kidney and liver cells. Traditional static cold storage was adequate for young, robust DBD organs traveling short distances. It is far less forgiving for an older DCD liver or a marginal kidney that must now cross a much larger geographic footprint to reach its recipient. The mismatch between a more fragile organ supply and a more dispersed allocation system is, in the authors’ framing, one of the central engineering problems of modern transplantation.
The technological response has been a rapid migration toward machine perfusion. Instead of passive storage on ice, machine perfusion devices pump preservation fluid through the organ, either chilled, as in hypothermic machine perfusion and hypothermic oxygenated perfusion, known as HOPE, or at body temperature, as in normothermic machine perfusion, NMP. Normothermic systems go further, delivering oxygenated blood or blood substitutes so the organ remains metabolically active, allowing clinicians to assess viability in real time and even to recondition organs that would otherwise be discarded. For lungs, ex vivo lung perfusion has enabled longer travel distances and ischemic times in the composite allocation score era, and clinical trials have shown that lungs can be preserved for up to 24 hours at 10 degrees Celsius without compromising outcomes after transplantation. For livers, normothermic machine perfusion has been shown to transform the logistics of transplantation, extending viable preservation windows and reducing the pressure of the race against the clock.
But this technological rescue comes with a bill. Machine perfusion devices, disposable perfusion circuits, and the trained personnel required to run them are expensive, and their use has grown alongside the shift toward DCD and marginal organs. National analyses of liver transplantation document a steep rise in ex situ machine perfusion use, and studies of cost reveal that these technologies add substantially to the standard acquisition cost of each organ. Compounding the problem, the review highlights troubling center-level variability in who actually receives perfused organs: research has found associations between a transplant center’s use of normothermic machine perfusion and the insurance status of its recipients, raising equity concerns about whether the benefits of expensive technology are distributed fairly. Meanwhile, organ acquisition charges, the costs transplant programs pass on to insurers and Medicare, have been climbing for years, with analyses of organ procurement organization cost reports showing that the price of procuring a kidney or liver has risen well beyond general medical inflation.
Policy changes have poured fuel on this fire. The Organ Procurement and Transplantation Network, operating under federal oversight, has spent the past decade dismantling the old donation service area boundaries that historically gave local patients first claim on local organs. First acuity-based liver allocation and then the composite allocation score, a continuous distribution framework, replaced geographic priority with a points-based system balancing medical urgency, waiting time, and travel-related logistics. The stated goal is laudable: organs should flow to the sickest patients wherever they live, not to whoever happens to be nearest the donor hospital. Kidney allocation moved to a circle-based system, and lung allocation adopted continuous distribution. The consequences for logistics, however, are measurable. Studies have documented a large increase in the volume of organ offers that transplant centers must evaluate, decreased efficiency in kidney placement, and longer travel distances and ischemic times for lungs, all of which multiply the coordination burden on procurement teams and add cost at every step.
Federal pressure has also targeted the performance of the organ procurement organizations themselves, the 50-odd nonprofit entities that hold exclusive contracts to coordinate donation within their territories. The Centers for Medicare and Medicaid Services has tightened its conditions of participation and performance evaluations for OPOs, and the Health Resources and Services Administration launched a modernization initiative for the OPTN aimed at increasing accountability. More recently, the CMS Increasing Organ Transplant Access model, or IOTA, is designed to push transplant hospitals to perform more transplants. Analyses of procurement activity following CMS performance evaluations suggest these interventions are reshaping OPO behavior. The cumulative effect is a system in which every participant, from the OPO to the transplant surgeon, faces intensifying metrics-driven pressure to recover and place more organs, including organs that a more conservative era would have declined.
The result, the review argues, is an industry straining against an architecture designed for a different time. Organ procurement remains vertically integrated: the OPO coordinates the donor, dispatches surgical teams, arranges preservation, and manages transport, while transplant centers absorb the acquisition costs through a reimbursement structure, the standard acquisition cost framework, that has not kept pace with modern practice. The authors point to emerging alternatives, including dedicated procurement entities and on-demand organ recovery services that decouple the surgical recovery step from the local OPO monopoly. Evidence from individual centers suggests that specialized donor surgeon involvement can reduce discards of marginal liver allografts, hinting that professionalized, high-volume procurement teams might extract more usable organs from the same donor pool. Normothermic regional perfusion, an alternative to super-rapid recovery in DCD that restores circulation to abdominal organs before retrieval, illustrates how technique choice at the donor hospital ripples through cost and quality downstream, and it remains a subject of active regulatory debate at HRSA.
What would redesign look like? The authors sketch a future in which procurement, preservation, and transport are disaggregated and each is optimized independently. Dedicated procurement organizations could concentrate surgical expertise and standardize recovery quality. Regional perfusion and preservation hubs, analogous to central laboratories, could receive organs, assess them on machine perfusion platforms, and hold them in extended preservation, using technologies like 10-degree lung storage or overnight normothermic liver perfusion to convert the frantic overnight transplant into a scheduled daytime operation. Modernized reimbursement would need to pay transparently for these services rather than burying them in acquisition charges, and quality metrics would need to align across OPOs, preservation centers, and transplant programs so that no participant is rewarded for shifting cost or risk onto another. The review is careful to note the goal: improved efficiency, cost control, and organ utilization without reducing patient access.
The stakes of getting this right are enormous. More than one hundred thousand Americans remain on transplant waiting lists, and every discarded organ represents a life not saved. Xenotransplantation looms on the horizon as a potential additional supply, but as the review’s own financial analysis of procurement suggests, even pig organs will flow through the same procurement, preservation, and allocation infrastructure, inheriting its inefficiencies unless the system is reformed first. The changing landscape of organ recovery is, at its core, a story about a public trust, the gift of donated organs, being handled by a logistics network that was never designed for older donors, warmer perfusion machines, and continent-wide allocation. Fleischer and Sheetz make the case that the coming decade will decide whether that network is deliberately re-engineered, or whether it simply continues to absorb complexity and cost until something gives.
Subject of Research: Trends in US deceased donor organ procurement, preservation technology, allocation policy, and costs
Article Title: The Changing Landscape of Organ Recovery: Recent Trends and Future Predictions
Article References: Fleischer, C. M., & Sheetz, K. H. (2026). The Changing Landscape of Organ Recovery: Recent Trends and Future Predictions. Current Transplantation Reports, 13(1), Article 32. https://doi.org/10.1007/s40472-026-00530-x
Image Credits: AI Generated
DOI: 10.1007/s40472-026-00530-x
Keywords: organ procurement, deceased donation, donation after circulatory death, machine perfusion, organ allocation, composite allocation score, organ procurement organizations, transplantation policy, ischemic time, organ acquisition costs, normothermic perfusion, health policy
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Ophelia Keating. (September 30, 2026). Older Donors, Warmer Organs: How the US Organ Recovery System Is Being Pushed to Its Limits. Scienmag. https://scienmag.com/older-donors-warmer-organs-how-the-us-organ-recovery-system-is-being-pushed-to-its-limits/
Ophelia Keating. “Older Donors, Warmer Organs: How the US Organ Recovery System Is Being Pushed to Its Limits.” Scienmag, 30 September 2026, https://scienmag.com/older-donors-warmer-organs-how-the-us-organ-recovery-system-is-being-pushed-to-its-limits/. Accessed 30 September 2026.
Ophelia Keating. “Older Donors, Warmer Organs: How the US Organ Recovery System Is Being Pushed to Its Limits.” Scienmag. September 30, 2026. https://scienmag.com/older-donors-warmer-organs-how-the-us-organ-recovery-system-is-being-pushed-to-its-limits/
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