Transcript Kidney Transplantation Committee Update

Kidney Transplantation
Committee Update
John J. Friedewald, MD
Committee Chair
Meetings
Ongoing Projects
 Progress
to develop a new national
kidney allocation system
 Recommendations
 Kidney
regarding variances
Paired Donation
NATIONAL KIDNEY ALLOCATION
SYSTEM
Progress Update

Simulation modeling completed and results reviewed by
Committee

Objectives for a new system were met (limitations of
current system addressed)

Committee voted to send out a policy proposal in the
fall
Current Working Model
Patients rank ordered by
• Waiting /ESRD time
• DR matching
• Sliding scale CPRA
System features
• A2 -> B
• Broader sharing CPRA>=98%
Top 20 % KDPI
to
Top 20 % EPTS
Patients rank ordered by
• Waiting/ESRD time
System features
• Regional sharing
• A2 -> B
•Broader sharing
CPRA>=98%
Allocation under “current rules”
(All Candidates)
Opt in system of
highest 15% KDPI
kidneys
“Think improved ECD”
0--------------------------------20-------------------------------------------------85------------------------100
KDPI Scale
Addressing System Limitations
Stated Limitation of the Current System
Applicable Concepts
Mismatch between potential survival of the kidney
and the recipient
Longevity matching
Variability in access to transplantation by blood group
and geographic location
A2/A2B, broader
sharing
High discard rates of kidneys that could benefit
candidates on the waiting list
KDPI, expedited
placement
Reduce differences in transplant access for
populations described in NOTA (e.g., candidates from
racial/ethnic minority groups, pediatric candidates,
and sensitized candidates).
ESRD time, broader
sharing, CPRA sliding
scale, maintain peds
priority
SIMULATION MODELING RESULTS
Summary Table
Average for 10 iterations
N1
N4
122,669
122,669
Average number of primary transplant recipients
(KI+KP)
11,531 (11,46311,586)
11,365 (11,32411,409)
Average median lifespan post-transplant (min, max of
runs)
11.82
(11.75 - 11.85)
12.73
(12.65-12.79)
Average median graft years of life (min, max of runs)
8.82
(8.80-8.84)
9.10
(9.08-9.12)
Average median extra life-years for tx recipient versus
waitlist candidate (min, max of runs)
5.01
(4.99-5.03)
5.27
(5.24-5.29)
Average median LYFT per transplant (min, max of runs)
5.70
(5.68-5.72)
5.97
(5.95-6.0)
Number of candidates (on waitlist at start or joining
during run)
Kidney Transplants by Recipient Blood Type
50
10.0
Difference in Percent from N1
45
40
Percent
35
30
25
20
15
10
8.0
6.0
4.0
2.0
0.0
-2.0
-4.0
5
-6.0
0
A
2010
AB
B
N1
O
N4
-8.0
A
AB
B
N4
O
Kidney Transplants by Recipient Age
10.0
Difference in Percent from N1
45
40
35
Percent
30
25
20
15
8.0
6.0
4.0
2.0
0.0
-2.0
-4.0
-6.0
10
-8.0
5
-10.0
<18
0
<18
18-34 35-49 50-64
2010
N1
65+
18-34
35-49
50-64
65+
N4
N4
To Table
10
50
45
40
35
30
25
20
15
10
5
0
Difference in Percent from N1
Percent
Kidney Transplants by Recipient Race
8
6
4
2
0
-2
-4
-6
-8
-10
N4
2010
N1
N4
Kidney Transplants by 0 HLA mismatches
10
9
8
Difference in Percent from N1
10
8
Percent
7
6
5
4
3
2
1
6
4
2
0
-2
-4
-6
-8
0
-10
0 Total HLA mismatches
2010
N1
N4
0 Total HLA mismatches
N4
Kidney Transplants by Organ Sharing
100
90
80
Percent
70
60
Local
50
Shared
40
30
20
10
0
2010
N1
N4
Kidney Transplants by Recipient CPRA, with waitlist
prevalence
60
Percent
50
40
30
20
10
0
Waitlist
2010
N1
N4
To Table
N3 versus N4
N3
N4
• Local CPRA 98-100
• Regional CPRA 98-100
• National CPRA 98-100
•
•
•
•
•
•
first priority for all
kidneys
first priority for all
kidneys
Local CPRA 100
Regional CPRA 100
National CPRA 100
Local CPRA 99
Regional CPRA 99
Local CPRA 98
Kidney Transplants by Recipient cPRA, 95-100
Percent of total KIA transplants
6
5
4
3
2
1
0
95
96
97
Waitlist
2010
98
N1
N3
99
100
N4
To Table
Kidney Transplants by Recipient CPRA
Difference in Percent from N1
4
2
0
-2
-4
-6
-8
-10
N4
To Table
Projected median patient years of life per transplant:
average, minimum, maximum of runs
11.82
(11.75, 11.85)
12.73
(12.65, 12.79)
12
10
8
6
4
2
0
N1
N4
Projected median graft years per transplant:
average, minimum, maximum of runs
9
8.82
(8.80, 8.84)
9.10
(9.08, 9.12)
N1
N4
8
7
6
5
4
3
2
1
0
Projected LYFT per transplant:
average, minimum, maximum of runs
6
5.70
(5.68, 5.72)
5.97
(5.95, 6.0)
N1
N4
5
4
3
2
1
0
VARIANCE REVIEW PROCESS
Variances
Reg 1
PADV
PATF
OKOP
VATB
TXSB
TXGC
The Committee received rationales from the above OPOs wishing to keep existing
variances in the new allocation system
Variance Recommendations

Discontinuation of all variances except for


Dialysis waiting time study
A2/A2B

Align changes to take place at the time a new
kidney allocation system is implemented

Allow applications for transition

Recommendations will be circulated for public
comment in the fall
Timeline for KAS and Variance
Proposals
Estimated Date
June 25, 2012
Fall 2012
June 2013
Fall 2013
TBD (likely 2014)
Action
OPTN/UNOS Board of Directors reviews
recommendations for discontinuation
(no action at this time)
Public Comment for new national kidney allocation
system and transition plans approved by the
Committee
Board of Directors considers proposal and transition
plans
Approved transition plans implemented
New kidney allocation system implemented and
transition plans ended
Kidney Paired Donation Pilot
Program Update
Overall Match Run Results
Candidates
Match Run Date Candidates Donors
Matched
November 15, 2011
134
146
8
December 12, 2011
144
158
10
January 25, 2012
104
117
7
February 23, 2012
128
142
13
March 21, 2012
145
163
27
April 4, 2012
135
150
5
April 19, 2012
151
169
24
May 2, 2012
150
167
16
May 16, 2012
151
167
5
June 12, 2012
154
170
16
June 19, 2012
148
163
16
TOTAL
Candidates
Transplanted
2
0
0
0
0
0
2 scheduled
0
2 pending
7 pending
7 pending
19, 16 pending
Barriers and Potential Solutions

Centers refusing matches based on combinations
of low-level antibodies
 Donor Pre-Select Tool

Frequency of match runs
 Now running matches twice a month
 Will increase frequency as resources allow but
ultimate flexibility depends on automation of
the match run
Barriers and Potential Solutions

Sizes of exchanges
 Testing a smaller exchange size (chain cap of 4)
in June match runs
June 12, 2012 Match Run Results (#22)
Participants included in the match
154 candidates (88 highly sensitized)
170 total donors
5 NDDs (2 A, 1 AB, 2 B)
48 centers from 11 regions had at least one eligible pair
Results
16 matched candidates (including waiting list candidates)
One 4-chain exchange, Two 3-chain exchanges, Two 3-ways
6 candidates have a CPRA>= 80%
3 NDDs who matched (1A, 2B)
KPD Work Group Activities
KPD Policy

Two proposals completing public comment:
 KPD Policy to replace Operational Guidelines
 Comments focused on histocompatibility section and
whether the program is ready for policy language
 Bridge Donor Proposal
 Public comment supportive of including bridge
donors

Both proposals likely to be forwarded to the Board in
November 2012
KPD Automated Solution
Update
Pre-Match Data Entry Screens

Released on December 12, 2011

Included the ability to:
 Enter KPD application from UNet℠
 Add and maintain donors and candidates
 Search for donors and candidates
 Verify ABO
 Print records
Eligibility Processing

Released on May 24, 2012:

Allows users to view whether candidates and
donors are eligible for the next match run in real
time

Includes warning messages for potential data
entry errors
Feedback from Users

“I really like the app and think it's user interface should
set the standard for other programs. It's a great first
step.”

“The addition of eligibility status to the UNet KPD
module is a HUGE benefit! I love it that it now tells what
is still missing, so we don't have to go hunting for it. Will
try to get some more pairs ready for next week's match
run. "
Future Functionality

Donor pre-select tool

Automation of the match run

Display of match results

Tracking of match responses
Questions?
BACKUP SLIDES
Counts of Kidney Transplants by Recipient CPRA
CPRA Group
Run
0
vs
N1
1-19
vs
N1
6609
759
-
6922 +313
775
2049
vs
N1
5079
vs
N1
8089
vs
N1
9094
vs
N1
95+ vs
N1
1001
-
805
-
748
+16
987
-14
766
-39
753
5555 -1054 578
-181
1236
+235 1255 +450
584
-164 +310 -84 1251 +772
5895 -714
-152
1291
+289 1311 +506
623
-126 +338 -57
N1
394
478
-
+368 -27
424
-54
N2
+5
N3
N4
607
681 +203
Back To Figure
Counts of Kidney Transplants by Recipient CPRA, 95+
CPRA Group
Run
95
vs
N1
96
vs N1
97
vs
N1
98
vs
N1
99
vs
N1
100
vs
N1
N1
81
-
101
-
94
-
61
-
71
-
71
-
N2
67
-14
87
-14
85
-9
54
-7
64
-7
67
-4
N3
59
-22
70
-31
74
-20
383
+322
398
+327
267
+196
N4
65
-16
75
-26
81
-13
68
+7
108
+37
284
+213
Back To Figure
Counts of Kidney Transplants, by Recipient Age
Age Group
Run
N1
N2
N3
N4
<18
vs N1
529
18-34
vs N1
35-49
vs N1
50-64
vs N1
65+
vs N1
1120
-
2719
-
4437
-
1991
-
475
-54
1178
+58
2765
+46
4540
+103
2036
+45
474
-55
1648
+528
3048
+329
3985
-451
1613
-378
491
-38
1668
+548
3012
+294
3948
-488
1625
-366
Back To Figure
Sharing by cPRA 98+
450
400
Transplant Counts
350
300
250
200
150
100
50
0
98 99 100 98 99 100 98 99 100 98 99 100
N1
N2
Local
Regional
N3
National
N4
Sharing by 0mm
100%
90%
80%
70%
60%
0MM and National
50%
0MM and Regional
40%
0MM and Local
30%
20%
10%
0%
N1
N2
N3
N4
Pediatric and Adult Transplants by Sharing
100%
90%
80%
70%
60%
National
50%
Regional
40%
Local
30%
20%
10%
0%
N1
N2
N3
Adult
N4
N1
N2
N3
Pediatric
N4
Adult and Pediatric Transplants by Top 20/Bottom 80
9000
2
8000
2
3
Transplant Counts
7000
3
6000
5000
8288
4000
3000
2000
1000
527
473
1978
2052
N1
N2
472
488
2901
2995
N3
N4
8467
7393
7259
N3
N4
0
N1
Top 20
N2
Bottom 80
Adult
Peds
Top 20 recipients by HLA-mismatch
30%
Percent of Transplants
25%
20%
Non-0 mm
0 mm
15%
10%
5%
0%
N1
N2
N3
Top 20
N4
N1
N2
N3
Bottom 80
N4
Sharing by run
Percent of organs that are
transplanted locally, by DSA
100
100
90
90
80
80
% local transplants in N3
% local transplants in N2
Percent of organs that are
transplanted locally, by DSA
70
60
50
40
30
20
70
60
50
40
30
20
10
10
0
0
0
•
•
20
40
60
80
% local transplants in N1
100
N2 projects a similar amount of sharing as N1
N3 projects fewer local transplants than N1
0
20
40
60
80
% local transplants in N1
100
Sharing by run, continued
Percent of organs that are
transplanted locally, by DSA
100
100
90
90
80
80
% local transplants in N4
% local transplants in N4
Percent of organs that are
transplanted locally, by DSA
70
60
50
40
30
20
70
60
50
40
30
20
10
10
0
0
0
•
•
20
40
60
80
% local transplants in N1
100
N4 projects fewer local transplants than N1
N4 projects more local transplants than N3
0
20
40
60
80
% local transplants in N3
100