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OPTN 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.

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Presentation on theme: "OPTN 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."— Presentation transcript:

1 OPTN 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 OPTN 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 OPTN 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 OPTN 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 OPTN 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 OPTN 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 OPTN DD Kidney New Allocation: Concepts (not policy) Estimation of DD kidney graft potential function: ECD or SCD KDPI: 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 OPTN 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 OPTN 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 OPTN Slide 10 Donor Age v. KDPI KDPI overlaps substantially for donors from most age categories

11 OPTN Slide 11 Donor Age by Recipient Age

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

13 OPTN 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:

14 OPTN 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 OPTN Median Expected Survival by Age for Active Kidney Candidates, 1/1/2004 Wolfe et al, SRTR simulation models

16 OPTN Median Expected Survival by Age Active Kidney Candidates, 1/1/2004 Wolfe et al, SRTR Simulation Models

17 OPTN Slide 17 Recipient Survival by Recipient Age and Donor DPI transplants

18 OPTN 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

19 OPTN The easy potential increase in kidney utilization

20 OPTN 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 OPTN % Deaths by Year by DPI among candidates >50 by decade of age

22 OPTN 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 OPTN 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 OPTN 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 OPTN 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 OPTN 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 OPTN 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 OPTN Is the Data Good Enough?

29 OPTN Thank you


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