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UNOS Kidney Committee Allocation Concepts: Not As Different As Some Want You to Believe…

UNOS Kidney Committee Allocation Concepts: Not As Different As Some Want You to Believe…. Ken Andreoni, MD Chair UNOS Kidney Comm The Ohio State University. DD Kidney Allocation Concepts. We are ONLY talking about standard ADULT Kidney only allocation today. We are NOT talking about:

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UNOS Kidney Committee Allocation Concepts: Not As Different As Some Want You to Believe…

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  1. UNOS Kidney Committee Allocation Concepts:Not As Different As Some Want You to Believe… Ken Andreoni, MD Chair UNOS Kidney Comm The Ohio State University

  2. DD Kidney Allocation Concepts • We are ONLY talking about standard ADULT Kidney only allocation today. We are NOT talking about: • Kidney with extra-renal organ (LK, HK, KP, etc.) • Pediatric – no change (except KDPI, not age) • Prior Living Donor category • O-MM National Sharing (CPRA >20) • Geography: being thoroughly investigated by other UNOS committees; complex issue

  3. DD Kidney Allocation Concepts • Though we think of allocating 10,000 deceased donor kidneys a year in the US, allocation is one kidney at a time… • This is why many theoretical allocation concepts do not work in reality!

  4. DD Kidney Allocation: Recent Change • 0 mm ABDR is local by category of CPRA, then regional or national for CPRA >20 only • This change has decreased the share of unsensitized 0 mm, and allowed more highly sensitized candidates to be transplanted nationally with less overall shipping of kidneys

  5. DD Kidney Allocation: TODAY • Estimation of DD kidney graft potential function: ECD or SCD • If ECD: goes to those on the local ECD list (by wait time) • If not accepted, then regional, then national ECD lists • If SCD: then all candidates locally by “points” • Wait time, HLA-DR matching (2 pts max), CPRA (>80 = 4 pts) • Then regional, then national by pts

  6. DD Kidney Allocation: TODAY • Most candidates at the top of list mostly by Wait Time • “If I just wait another week/month, could I get a much better kidney?” • Makes very inefficient use of very useable kidneys • Patients and Transplant Professionals need better educational tools to decide about the trade-off: time to transplant vs. quality of organ

  7. DD Kidney New Allocation: Concepts (not policy) • Estimation of DD kidney graft potential function: ECD or SCD “KDPI”: < or > 20% • If KDPI is 21 to 100%, first offered to all within 15 years of donor age (30 yr span) • This large group rank ordered (WT, CPRA, HLA) • If not accepted, then to those outside of 15 yrs local, then regional, then national • If KDPI <=20%; then first to candidates with Est Post-Tx Survival longest 20% • If not accepted, then to all local, then regional, then national

  8. SCD vs ECD: Overlap Too many candidates are listed for ECD Waiting for the ‘Good ECD’ Despite this survival overlap, the current system leads to higher discard rates for potential well functioning kidneys that are labeled ECD

  9. KDPI vs ECD • KDPI • Donor age (c) • Race/ethnicity • Hypertension • Diabetes • Serum creatinine (c) • COD CVA • Height • Weight • DCD • HCV • ECD • Donor Age • >60 alone • Donor Age • >50 with two below: • Cr >1.5 • HTN • CVA • RR of graft failure >1.7 compared to the ‘ideal’ donor (16 – 17%)

  10. Donor Age v. KDPI KDPI overlaps substantially for donors from most age categories Slide 10

  11. Donor Age by Recipient Age Slide 11

  12. Distribution of Relative Risks for Donor Kidneys: 2004-2007 Relative Risk for graft failure is not markedly different for top 20% of kidneys Uses donor factors only

  13. +- 15 years: mostly what we already do… Median age difference is 14 years in the US 25% of DD txs <6 yrs apart 75% < 26 yrs apart Donors <35 yo are 41% of donors Donors <=35, mean recipient age is 49 Recip >65 more than half of donors >50yo Segev DL. Evaluating Options… AJT 2009; 9:1513-18

  14. DD Kidney Utilization Estimation of DD kidney graft potential function: ECD/SCD vs KDPI Education of potential benefit to recipients (and transplant professionals) Quality of organ vs. prolonged wait time for better organ

  15. Median Expected Survival by Agefor Active Kidney Candidates, 1/1/2004 Wolfe et al, SRTR simulation models

  16. Median Expected Survival by AgeActive Kidney Candidates, 1/1/2004 Wolfe et al, SRTR Simulation Models

  17. Recipient Survival by Recipient Age and Donor DPI Slide 17 2005-2007 transplants

  18. Hypothetical Output from an Educational Tool to help Candidates and Transplant Professionals Make More Informed Decisions on Organ Acceptance: Candidate of X yrs old, with Y, Z co-morbidities, living in a DSA C 5 4 3 2 1

  19. The easy potential increase in kidney utilization

  20. DD Kidney Utilization Estimation of DD kidney graft potential function: ECD/SCD vs KDPI Education of potential benefit to recipients Transplant Center Outcome reports

  21. % Deaths by Year by DPI among candidates >50 by decade of age

  22. Big Picture Slide: Most with ESRD do not live to avg. pop lifetime, Transplantation is good for most candidates, young w ESRD lose more years from their expected lifetime

  23. Who is the Sickest? Die first? Like MELD for liver Then we transplant all sicker and older pts Who loses the most years from their disease? 25yo on HD:13 yrs, w Tx:34 yrs 60yo on HD: 5 yrs, w Tx:12 yrs 25yo unlikely to reach age 60 w Tx 25yo will die at <40 yrs of age on HD 25yo gains 21 yrs of survival, 60yo gains 7 yrs of survival w Tx 25yo lives 13 yrs on HD, 60yo lives 12 yrs w Tx

  24. ‘A Kidney That Looks Like You’ All candidates of all ages have access Access for most candidates does NOT change The average candidate will receive the SAME quality kidney Will only prevent transplantation across many decades of age differences All candidates may benefit…why? Improvement of utilization of kidneys by KDPI and understanding of age ranges should increase transplantation of appropriate kidneys, especially to older candidates Public understanding of system to increase donation

  25. ‘A Kidney That Looks Like You’ Living Donation should not be influenced in the negative: No one goes to the front of the line Whether within 30 year age group, or “top 20%” everyone within that group is then equal and put in order by variables such as: Wait time, CPRA, HLA, etc., so everyone will wait for their DD offer NOT similar to the Pediatric Share 35 situation that occurred in some DSAs

  26. Is the Data Good Enough? 80% of organs first to candidate group within 15 years (30 yr range) Rank-ordered by variables similar to today such as Wait Time, CPRA, HLA match, etc. Clinical common sense Alignment of potential function of organ to post-transplant potential survival 20% DPI and EPTS Predictive models are reasonably good to predict the longest potential functioning organs and longest surviving recipient

  27. C Statistic • Measure of “goodness of fit”, or how accurately does this tool tell two people apart everywhere on the list • It gives the same weight to tell number 1 from number 10,000, as it does from telling number 5,000 from number 5,001 • The first is important in allocation, the later is not!

  28. Is the Data Good Enough?

  29. Thank you

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