Download - Kidney Transplantation Committee Update
Kidney Transplantation Committee Update
John J. Friedewald, MDCommittee Chair
Meetings
Progress to develop a new national kidney allocation system
Recommendations regarding variances Kidney Paired Donation
Ongoing Projects
NATIONAL KIDNEY ALLOCATION SYSTEM
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
Progress Update
Top 20 % KDPIto
Top 20 % EPTS
Allocation under “current rules”(All Candidates)
Opt in system of highest 15% KDPI
kidneys“Think improved ECD”
Patients rank ordered by•Waiting /ESRD time•DR matching•Sliding scale CPRA System features•A2 -> B•Broader sharing CPRA>=98%
Patients rank ordered by• Waiting/ESRD timeSystem features• Regional sharing• A2 -> B•Broader sharing CPRA>=98%
Current Working Model
0--------------------------------20-------------------------------------------------85------------------------100KDPI Scale
Addressing System LimitationsStated 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
Number of candidates (on waitlist at start or joining during run)
122,669 122,669
Average number of primary transplant recipients (KI+KP)
11,531 (11,463-11,586)
11,365 (11,324-11,409)
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)
0
5
10
15
20
25
30
35
40
45
50
A AB B O
Perc
ent
2010 N1 N4
-8.0
-6.0
-4.0
-2.0
0.0
2.0
4.0
6.0
8.0
10.0
A AB B O
Diff
eren
ce in
Per
cent
from
N1
N4
Kidney Transplants by Recipient Blood Type
0
5
10
15
20
25
30
35
40
45
<18 18-34 35-49 50-64 65+
Perc
ent
2010 N1 N4
-10.0
-8.0
-6.0
-4.0
-2.0
0.0
2.0
4.0
6.0
8.0
10.0
<18 18-34 35-49 50-64 65+
Diff
eren
ce in
Per
cent
from
N1
N4
Kidney Transplants by Recipient Age
To Table
05
101520253035404550
Perc
ent
2010 N1 N4
-10-8-6-4-202468
10
Diff
eren
ce in
Per
cent
from
N1
N4
Kidney Transplants by Recipient Race
0
1
2
3
4
5
6
7
8
9
10
0 Total HLA mismatches
Perc
ent
2010 N1 N4
-10
-8
-6
-4
-2
0
2
4
6
8
10
0 Total HLA mismatches
Diff
eren
ce in
Per
cent
from
N1
N4
Kidney Transplants by 0 HLA mismatches
0
10
20
30
40
50
60
70
80
90
100
2010 N1 N4
Perc
ent
Local
Shared
Kidney Transplants by Organ Sharing
0
10
20
30
40
50
60
Perc
ent
Waitlist 2010 N1 N4
Kidney Transplants by Recipient CPRA, with waitlist prevalence
To Table
N3 versus N4
N3 N4
• Local CPRA 98-100• Regional CPRA 98-100• National CPRA 98-100
first priority for all kidneys
• Local CPRA 100• Regional CPRA 100• National CPRA 100• Local CPRA 99• Regional CPRA 99• Local CPRA 98
first priority for all kidneys
Kidney Transplants by Recipient cPRA, 95-100
0
1
2
3
4
5
6
95 96 97 98 99 100
Perc
ent o
f tot
al K
IA tr
ansp
lant
s
Waitlist 2010 N1 N3 N4
To Table
Kidney Transplants by Recipient CPRA
-10
-8
-6
-4
-2
0
2
4
Diff
eren
ce in
Per
cent
fro
m N
1
N4
To Table
Projected median patient years of life per transplant: average, minimum, maximum of runs
Projected median graft years per transplant: average, minimum, maximum of runs
Projected LYFT per transplant:average, minimum, maximum of runs
VARIANCE REVIEW PROCESS
Variances
The Committee received rationales from the above OPOs wishing to keep existing variances in the new allocation system
PADVPATF
TXSBTXGC
OKOP VATB
Reg 1
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
Variance Recommendations
Estimated Date Action
June 25, 2012 OPTN/UNOS Board of Directors reviews recommendations for discontinuation(no action at this time)
Fall 2012 Public Comment for new national kidney allocation system and transition plans approved by the Committee
June 2013 Board of Directors considers proposal and transition plans
Fall 2013 Approved transition plans implementedTBD (likely 2014) New kidney allocation system implemented and
transition plans ended
Timeline for KAS and Variance Proposals
Kidney Paired Donation Pilot Program Update
Overall Match Run Results
Match Run Date Candidates Donors Candidates Matched
Candidates Transplanted
November 15, 2011 134 146 8 2December 12, 2011 144 158 10 0January 25, 2012 104 117 7 0February 23, 2012 128 142 13 0March 21, 2012 145 163 27 0April 4, 2012 135 150 5 0April 19, 2012 151 169 24 2 scheduledMay 2, 2012 150 167 16 0May 16, 2012 151 167 5 2 pendingJune 12, 2012 154 170 16 7 pendingJune 19, 2012 148 163 16 7 pending
TOTAL 19, 16 pending
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
Barriers and Potential Solutions
June 12, 2012 Match Run Results (#22)
Participants included in the match154 candidates (88 highly sensitized)
170 total donors5 NDDs (2 A, 1 AB, 2 B)
48 centers from 11 regions had at least one eligible pair
Results16 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
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 Policy
KPD Automated Solution Update
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
Pre-Match Data Entry Screens
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
Eligibility Processing
“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. "
Feedback from Users
Donor pre-select tool
Automation of the match run
Display of match results
Tracking of match responses
Future Functionality
Questions?
BACKUP SLIDES
Counts of Kidney Transplants by Recipient CPRA
CPRA Group
Run 0 vs N1
1-19 vs N1
20-49
vs N1
50-79
vs N1
80-89
vs N1
90-94
vs N1
95+ vs N1
N16609 759 - 1001 - 805 - 748 394 478 -
N26922 +313 775 +16 987 -14 766 -39 753 +5 +368 -27 424 -54
N35555 -1054 578 -181 1236 +235 1255 +450 584 -164 +310 -84 1251 +772
N45895 -714 607 -152 1291 +289 1311 +506 623 -126 +338 -57 681 +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 <18 vs N1 18-34 vs N1 35-49 vs N1 50-64 vs N1 65+ vs N1
N1529 1120 - 2719 - 4437 - 1991 -
N2475 -54 1178 +58 2765 +46 4540 +103 2036 +45
N3474 -55 1648 +528 3048 +329 3985 -451 1613 -378
N4491 -38 1668 +548 3012 +294 3948 -488 1625 -366
Back To Figure
Sharing by cPRA 98+
0
50
100
150
200
250
300
350
400
450
98 99 100 98 99 100 98 99 100 98 99 100
N1 N2 N3 N4
Tran
spla
nt C
ount
s
Local Regional National
Sharing by 0mm
Pediatric and Adult Transplants by Sharing
Adult and Pediatric Transplants by Top 20/Bottom 80
Top 20 recipients by HLA-mismatch
Sharing by run
• N2 projects a similar amount of sharing as N1• N3 projects fewer local transplants than N1
Sharing by run, continued
• N4 projects fewer local transplants than N1• N4 projects more local transplants than N3