Transcript priority - Transplant Pro

Kidney Transplantation Committee
Spring 2014
Allocation component changes
1. Waiting time calculation - pre-registration dialysis
time added
2. Candidate classification - Estimated Post
Transplant Survival (EPTS) score
3. Kidney donor classification - replace SCD/ECD
with Kidney Donor Profile Index (KDPI)
4. Priority for sensitized candidates - calculated
panel reactive antibody (CPRA) sliding scale
Allocation component changes
5. Blood type eligibility - A2 and A2B to B compatible
6. Pediatric kidney allocation – KDPI priority
7. Kidney payback policy – eliminated
8. Kidney variances – eliminated
Importance of early referral
Communicate with referring physicians:
o
Pre-emptive listing is still advantageous
o
Candidates can accrue time with GFR<=20ml/ml
o
Priority for 0-ABDR mismatch offers
Change #1 – Waiting time
Current
Adult
Accrue time when
listed, and:
New
or
Accrue time when listed,
and:
on dialysis (with credit
for time spent on
dialysis prior to listing)
or
when GFR or CRCL
is =/< 20 ml/min
when GFR is =/< 20
ml/min
on dialysis
Change #1 – Waiting time
Current
Pediatric
Accrue time
immediately when
listed
New
Accrue time immediately
when listed
and
Credit for time spent on
dialysis before listing
Change #2: Candidate classification
Current
No priority based on estimated posttransplant survival
New
The 20% of adult candidates who have
the longest EPTS receive priority for
kidneys from donors with KDPI scores
in the top 20%.
Estimated Post Transplant Survival

EPTS data variables
o
o
o
o

Age
Prior transplant
Diabetes status
Time on dialysis
EPTS score range is 0 - 100%
Sequence A
Sequence B
Sequence C
Sequence D
KDPI <=20%
KDPI >20% but
<35%
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living donor
Local
Regional
National
KDPI>85%
Highly Sensitized
0-ABDRmm (top
20% EPTS)
Prior living donor
Local pediatrics
Local top 20%
EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Local + Regional
National
Longevity matching
Action: Review waiting time
Mid–2014
System tools
• Review dialysis start dates
• Confirm or update dialysis start dates
• Retain documentation of dialysis start dates
• System will cross-reference CMS Crown database
(including Form 2728)
• Flag data inconsistencies
Action: Input and confirm data
Begin Now
• Get familiar with the EPTS calculator
Mid–2014
• Enter data in fields used to calculate EPTS
System tools
• Editable data in the system
• Cross-references to OPTN and CMS dialysis dates
• Flags for data inconsistency
Action: Assess for living donors

Prior living donors get 4 points
Begin now
• Check candidates for prior organ donation
• Retain documentation of prior donation
Change #3 - Kidney classification
Current
Classified as SCD or ECD based on:
o donor age
o history of hypertension
o creatinine
o cerebrovascular accident as
cause of death
New
Classified by KDPI based on:
o donor age
o height
o weight
o ethnicity
o history of hypertension
o history of diabetes
o cause of death
o serum creatinine
o hepatitis C virus status
o donation after circulatory death
Acceptance criteria

Other independent acceptance criteria may conflict
with KDPI

Examples:
o
candidate opts out of DCD but selects KDPI max of 60%
= will not see any DCD offers, even from KDPI 50% or
less donors
o
candidate selects max donor age of 55 and KDPI of 60%
= will not see offers from 56 y/o donor with KDPI 36%
Action: Update acceptance criteria
Begin now
Mid-2014
• Review listed candidates for criteria entered
• Discuss acceptance criteria for local versus import
• Determine candidates that may benefit from a
shipped KDPI>85% organ
• Enter KDPI acceptance criteria
• Assess for KDPI and “other” criteria conflicts
Action: Update consents
Begin now
• Update consent forms - KDPI > 85% instead of ECD
Implementation
• New candidates listed must be consented if willing
to accept KDPI>85%
• Currently listed candidates • Willing to accept ECD? default to 0-100% KDPI
• Not willing to accept ECD? default to 0-85% KDPI
Tools available
Summer 2014
• Sample language for discussing KDPI with patients
• Patient brochure
Change #4 - Sensitized candidates
Current Priority
CPRA score at or above 80%
receives 4 points
Moderately sensitized (CPRA
0-79%) receive zero points
New Priority
CPRA scores of 20% or above
receive points based on a sliding
scale
Sequence A
Sequence B
Sequence C
Sequence D
KDPI <=20%
KDPI >20% but
<35%
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living donor
Local
Regional
National
KDPI>85%
Highly Sensitized
0-ABDRmm (top
20% EPTS)
Prior living donor
Local pediatrics
Local top 20%
EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Local + Regional
National
Highly sensitized
before 0-ABDR
Action: Update unacceptable antigens
(UAs)
Begin now
Prior to
implementation
• Review unacceptable antigens reported
• Enter any unacceptable antigens not previously
entered (according to your center’s protocol)
Action: Review and Approve UAs
Mid–2014
• Reports will appear to allow Lab director and
transplant physician/surgeon to approve
unacceptable antigens for candidates already listed
with CPRA greater than 98%
System tools
• Message and printable form will display when CPRA
99-100% is reached
• Report listing candidates who require approvals
Change #5 - Blood type eligibility
Current
New
Kidneys allocated to candidates
who are blood type identical to
the donor when the donor has
blood type O or B. Blood type B
candidates are ineligible for
A2/A2B offers.
Blood type B candidates that meet
defined clinical criteria are eligible for
kidneys from donors with blood type A2
or A2B.
Action: Develop clinical criteria
Begin now
• Create a protocol - maximum titer levels acceptable
for blood type B candidates to blood type A2 or A2B
donors
Mid–2014
• Enter whether candidate meets criteria - yes or no
• Retain documentation of titer levels
After
implementation
• Update eligibility every 90 days
Implementation
Phase I
• Data updates begin
• New reports released
• Calculators made available
Summer 2014
Phase II
• New allocation rules applied
• Variances turned off
• Payback system turned off
December 2014
Save the date
April 24, 2014 @ 2 p.m. (ET)
The New Kidney Allocation System: Resources
for Protocols and Processes webinar
More information
Recorded webinars, podcasts, toolkits, etc. available
on:
OPTN web site - http://optn.transplant.hrsa.gov (click
‘Resources’ and ‘Professional Resources’)
Transplant Pro* - http://transplantpro.org (click ‘I am
Looking For’ and ‘Kidney Allocation System’)
*These are a service of United Network for Organ Sharing and are not produced
under the OPTN contract.
Subscribe to RSS feeds and a monthly newsletter at
http://www.transplantpro.org
Questions?

Richard Formica, MD
Committee Chair

Name
Region # Representative
Email

Gena Boyle
Committee Liaison
[email protected]
Backup Slides
KDPI
Point changes: Sensitization
Points
CPRA Sliding Scale (Allocation Points)
20
18
16
14
12
10
8
6
4
2
0 0
0
(CPRA<98%)
17.30
New
12.17
10.82
Current
0
0
10
0.21
0.08
20
30
0.48
0.34
40
50
CPRA
CPRA
0.81 1.09
60
70
6.71
1.58
4.05
2.46
80
90
100
Summary: Member responsibilities
Communicate importance of early
referral
Establish protocols for A2 and A2B
donors to B candidates
Report/update data to calculate
EPTS and waiting time
Review candidates to identify prior
living organ donors
Establish KDPI acceptance criteria Review waiting list for unacceptable
and update consents for KDPI>85% antigens
Review “other” donor screening
criteria
Educate candidates and potential
candidates on changes