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.