Background. There are known racial disparities in the organ transplant allocation system in the United States. However, prior work has yet to establish if transplant center decisions on offer acceptance—the final step in the allocation process— contribute to these disparities.

Objective To estimate racial differences in the acceptance of organ offers by transplant center physicians on behalf of their patients.

Design Retrospective cohort analysis using data from the Scientific Registry of Transplant Recipients (SRTR) on patients who received an offer for a heart, liver, or lung transplant between January 1, 2010 and December 31, 2020.

Setting Nationwide, waitlist-based.

Patients 32,268 heart transplant candidates, 102,823 liver candidates, and 25,780 lung candidates, all aged 18 or older.

Measurements 1) Association between offer acceptance and two race-based variables: candidate race and donor-candidate race match; 2) association between offer rejection and time to patient mortality.

Results Black race was associated with significantly lower odds of offer acceptance for livers (OR=0.93, CI: 0.88-0.98) and lungs (OR=0.80, CI: 0.73-0.87). Donor-candidate race match was associated with significantly higher odds of offer acceptance for hearts (OR=1.11, CI: 1.06-1.16), livers (OR=1.10, CI: 1.06-1.13), and lungs (OR=1.13, CI: 1.07-1.19). Rejecting an offer was associated with lower survival times for all three organs (heart hazard ratio=1.16, CI: 1.09-1.23; liver HR=1.74, CI: 1.66-1.82; lung HR=1.21, CI: 1.15-1.28).

Limitations Our study analyzed the observational SRTR dataset, which has known limitations.

Conclusion Offer acceptance decisions are associated with inequity in the organ allocation system. Our findings demonstrate the additional barriers that Black patients face in accessing organ transplants and demonstrate the need for standardized practice, continuous distribution policies, and better organ procurement.

The authors have declared no competing interest.

This work was supported by funding from the MIT Jameel Clinic. This research was supported, in part, by Takeda Development Center Americas, INC. (successor in interest to Millennium Pharmaceuticals, INC.). RSB is supported by an NIH Ruth L. Kirschstein National Research Service Award (T32HL116275). MG is supported in part by a CIFAR AI Chair at the Vector Institute. LAC is funded by the National Institute of Health through the NIBIB R01 grant EB017205.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study was granted full approval following expedited review by the Committee on the Use of Humans as Experimental Subjects, the Institutional Review Board for the Massachusetts Institute of Technology.

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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This study used data from the Scientific Registry of Transplant Recipients (SRTR).