5 evolving challenges facing OPOs and how technology 
can help unlock more viable organs

1. A Persistent Gap Between Organ Supply and Demand

The most fundamental challenge remains unchanged: there are not enough viable organs. More than 100,000 patients in the United States are currently waiting for a transplant, with thousands dying each year while waiting.¹

Importantly, many potential donor organs are never utilized—not due to lack of availability, but because they are deemed non-viable at procurement. This highlights a critical opportunity: improving donor management to increase utilization.

2. Physiologic Instability After Brain Death

Brain death triggers profound physiologic changes that threaten organ viability, including hemodynamic instability, systemic inflammation, and impaired oxygenation.²

The lungs are particularly vulnerable:

• Atelectasis due to loss of respiratory drive 
• Ventilation-perfusion (V/Q) mismatch 
• Ventilator-associated lung injury

These factors often result in lungs—and sometimes additional organs—being ruled out despite otherwise suitable donor profiles.

3. Suboptimal Ventilation Strategies

Even when best practices are known, they are not consistently applied. Studies show that only about 25% of donors receive lung-protective ventilation, despite strong evidence linking it to increased lung procurement rates.³

This gap underscores a broader issue: inconsistency in execution across care settings.

4. Variability Across Hospitals and Care Teams

OPOs operate across a wide range of hospital environments with varying:

• Staffing levels 
• Clinical expertise 
• Protocol adherence 

This variability leads to uneven donor management and inconsistent outcomes. Regulatory changes have introduced standardized performance metrics, but bedside variability remains a major barrier.⁴

5. Workflow Burden and Staffing Constraints

Critical care teams are frequently resource-constrained. Interventions like prone positioning,while clinically beneficial, have challenges:

• Labor-intensive 
• Physically demanding 
• Time-sensitive 
• Inconsistently implemented 

As a result, high-impact therapies may be underutilized simply due to operational challenges.

Why Ventilation and Perfusion Are Central to Organ Viability

Adequate ventilation and perfusion are foundational to maintaining organ function in donors.

Poor oxygenation has cascading effects:

• Lungs: Increased atelectasis and reduced transplant eligibility 
• Heart: Impaired myocardial performance 
• Liver and kidneys: Increased susceptibility to ischemic injury 

In essence, suboptimal lung management compromises multi-organ viability.

The Role of Prone Positioning in Donor Optimization

Prone positioning is a well-established intervention that improves pulmonary physiology. In the context of donor management, it represents one of the most impactful yet underutilized tools available to improve organ viability.

Physiologic Benefits

Proning has been shown to:

• Improve ventilation-perfusion matching 
• Increase oxygenation 
• Reduce atelectasis 
• Promote more uniform lung recruitment⁵ 

These effects directly address the mechanisms that often render donor lungs unusable.

Evidence Linking Proning to Increased Lung Utilization

Beyond physiologic improvements, clinical data demonstrates that prone positioning can directly increase transplantable organ yield.

Macklin et al. evaluated prone positioning in brain-dead donors and found that:

• Proning rapidly reversed atelectasis and hypoxemia 
• PaO₂/FiO₂ ratios improved significantly, often shifting donors into transplant-eligible ranges 
• Most importantly, these improvements translated into a higher number of lungs being transplanted⁶ 

This is a critical distinction: prone positioning is not just improving numbers on a monitor, it is changing clinical decision-making and increasing organ utilization.

Additional reports further reinforce this finding, showing that:

• Lungs initially deemed non-viable can become transplantable after prone positioning 
• Improvements in oxygenation can occur within hours, making this a time-sensitive and high-impact intervention⁷ 

For OPOs, this highlights a key opportunity: lung viability is often dynamic and can be actively improved with the right intervention at the right time.

Impact Beyond the Lungs

The benefits of prone positioning extend beyond pulmonary outcomes.

Improved oxygenation:

• Enhances systemic oxygen delivery 
• Supports cardiac performance 
• Preserves liver and kidney function 

Importantly, prone positioning has been shown to:

• Maintain hemodynamic stability
• Avoid negative effects on other transplantable organs⁵ 

This reinforces a central principle in donor management: optimizing the lungs supports the viability of all organs.

The Implementation Gap

Despite strong evidence, prone positioning remains inconsistently utilized due to operational barriers.

Manual proning:

• Requires multiple caregivers 
• Carries risk of staff injury 
• Is difficult to standardize 
• Varies widely across institution 

As a result, there is a clear gap between what is clinically effective and what is consistently implemented.