*Purpose: To determine the reasons that deceased donor organs were allocated but not transplanted (TXP) in a large organ procurement organization (OPO).

*Methods: All organs allocated and not recovered or discarded in a single OPO from 1/1/19 – 10/28/19 were included. Donor were identified as brain dead (BD) or DCD. Pancreas appearance was described as A (usable, perfect organ), B (mild disease, <20% fat infiltrate, mild nodularity) or C (not usable, >20% fat, significant nodularity).

*Results: LIvers were transplanted from 201/277 (73%) donors. In 22 cases the intent had been to TXP but an obstacle arose (DCD long warm time = 5, Intraoperative finding = 11, Surgical error – 1, Biopsy finding – 2, ITP – 1, Recipient instability – 2). An additional 12 livers were allocated without any interest (DCD – 5, BD – 7), age range 58 – 92 years.

There was intent to TXP a pancreas in 48 cases; of these 17 (35%) were not TXP including 9 A grade organs. Preventable loss was identified in 5/9 due to Surgical error – 1, Logistics – 1, Replaced R Hepatic Artery – 1, Acute Kidney Injury -2).

Kidney discards (N=108) included both organs from the same donor (N=78). But 17 kidneys whose mate kidney was TXP were discarded; DCD = 5 (KDPI 51 – 62), BD = 12 (KDPI 10 -67). 7/17 TXP mate kidneys functioned immediately.

Entry to the OR with intent to TXP both lungs but decline of both lungs involved 24 lungs (DCD – 2 donors, BD – 10 donors). The age range was 21 – 62 years. The peak O2 ranged from 399 – 530.

Intent to TXP hearts with an outcome of no TXP was identified in 5 cases. 4/5 functioned poorly on visualization. The 5th was discarded because the surgical team’s return flight (with the heart) was diverted for bad weather and cold ischemia time became excessive.

*Conclusions: In real time, aggressive efforts were utilized to successfully allocate many more deceased donor organs than were ultimately transplanted. This retrospective analysis demonstrates that a small proportion were lost due to unavoidable problems. However, a significant number of organs, most of which were marginal, might have been transplanted with the use of specific strategies such as minimization of cold ischemia, ex vivo pumping, and/or informed patient consent. Careful scrutiny of organs offered for allocation but not ultimately transplanted should continue.

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