1. OPTN Liver and Intestinal Organ Transplantation Committee Update Spring 2012 Kim Olthoff, MD, Chair David Mulligan, MD, Vice-chair

2. OPTN Proposals Circulated Fall 2011  Public Comment ended 12/23/2011  Committee met 03/15/2012, reviewed comments Share 15 National will be submitted to the Board of Directors in June Share 35 Regional - Several decisions: Will apply to MELD/PELD exceptions No Sharing Threshold Awaiting data on Liver-Kidney before decision Will meet by call in April or May to vote on Board submission

3. OPTN Other Committee Initiatives  MELD Enhancements & Exceptions Subcommittee MELD Refit (with or without Na) Review of issues with MELD/PELD exceptions / Review Boards Revisit PELD Score  Liver Utilization Subcommittee Reducing discards “Facilitated Placement”

4. OPTN Other Committee Initiatives  HCC Subcommittee Explant Pathology Form – Going online Will replace faxed forms System notice 2 weeks prior HCC Hold Proposal (Spring 2012) HCC Allocation Issues  Status 1 Review Subcommittee Ongoing real-time review of Status 1A/B cases not meeting criteria

5. OPTN Questions?

6. OPTN Liver and Intestinal Organ Transplantation Committee Proposal for Public Comment Spring 2012

7. OPTN Proposal to Allow Centers to Place Liver Candidates with HCC Exceptions on ‘HCC Hold’ Without Loss of Accumulated MELD Exception Score (“HCC Hold”)

8. OPTN PROBLEM STATEMENT / BACKGROUND

9. OPTN Problem Statement - I Currently:  Candidates listed with an HCC exception continue to receive increases in priority every three months regardless of whether the tumors have shown progression  As score increases (22, 25, 28, etc.) candidates begin to receive offers  Centers may wish to inactivate some candidates until there is demonstrated tumor progression: Candidates initially listed with small tumors Those with well-treated tumors

10. OPTN Problem Statement - II  No mechanism to do this without: Automatic increases in score (if extended while inactivated) OR Loss of accumulated score (if not extended while inactive  If inactivated, centers must submit extensions every three months Otherwise candidate loses accumulated MELD score Score continues to increase even though risk of drop-out may be low

11. OPTN Proposal  Allow centers to place liver candidates with HCC Exceptions on ‘HCC Hold’ without loss of accumulated MELD exception score and without mandatory/standard increases in the score q 3 mo  In practice: Candidate is inactivated, reason provided is “HCC hold”

12. OPTN Benefits  Will eliminate offers for high-MELD patients that the center is not yet ready to transplant Improve efficiency of the system (fewer turndowns) Decrease required applications for extensions, and tests required to complete applications  Allows centers to utilize different ways of treating these patients (e.g., TACE, RFA), while providing the safety net of transplant if/when tumor recurs or demonstrates growth

13. OPTN Summary Current Process in UNet ℠ Proposed Change Centers can extend an approved HCC Exception while candidate is in inactive status. No change. Approved HCC Exception applications must be extended every 3 months, even while the candidate is in inactive status. If the application is not extended, the candidate will lose the accumulated exception score upon re-activation. Approved HCC Exception applications may remain on ‘HCC hold’ as long as a candidate is in inactive status; once re-activated, the candidate will retain the accumulated exception score (most recent tumor information must be provided).

14. OPTN Current Process in UNet ℠ Proposed Change Upon extension of an approved HCC Exception, the MELD score increases by the equivalent of a 10 percentage point increase in the risk of 3- month mortality. Upon re-activation and extension of an approved HCC Exception, the MELD score could remain fixed. Summary II

15. OPTN Example A (p. 62 of proposal)  1/1/2012: Candidate has approved HCC exception, one 2.1 cm tumor (MELD 22).  Exception extended 4/1 (25) and 7/1 (28).  Candidate begins receiving offers; tumor size still 2.1cm  Transplant team decides to observe tumor behavior before proceeding to transplant  Candidate placed on “HCC hold,” periodically undergoes CT to monitor the lesion.

16. OPTN Example A (p. 62 of proposal)  12/10/12: CT shows tumor has grown to 2.8 cm.  12/15/12: Center submits the routine tumor information and activates candidate  Candidate’s score of 28 maintained until the next extension

17. OPTN Example B (p. 62 of proposal)  1/1/2012: Candidate has approved HCC exception, one tumor treated with RFA that is 2.5 cm in size (MELD 22).  Exception extended 4/1 (25) and 7/1 (28).  Candidate begins receiving offers, however the candidate has an ablation defect with no evidence of viable tumor  Transplant team decides to observe tumor behavior before proceeding to transplant.  Candidate placed on “HCC hold,” periodically undergoes CT to monitor the lesion.

18. OPTN Example B (p. 62 of proposal)  1/1/13: CT shows no evidence of viable tumor at the ablation site but a new 1cm hypervascular lesion with wash out on delayed phase imaging.  1/5/13: Center submits the routine tumor information and activates candidate.  Candidate’s score of 28 is maintained until the next extension

19. OPTN Supporting Data  Candidates with small HCC tumors have a low probability of waiting list dropout or growth beyond current transplant criteria within 12 months of listing Washburn et al, AJT 2010 Massie, et al, AJT 2011

20. OPTN Policy The following options are available while a candidate with an approved HCC Exception application is in inactive status: T he center may choose to submit an extension application every 3 months, as described above; the candidate will receive a MELD/PELD score equivalent to a 10 percentage point increase in candidate mortality following each approved extension.

21. OPTN Policy The center may keep the candidate in inactive status for any length of time, without submission of an extension application every 3 months. However, prior to reactivation, an extension application must be submitted. Once the extension application is approved, the candidate will be listed with the candidate’s previously approved exception score prior to inactivation (i.e., without loss of the accumulated MELD/PELD exception score) upon re-activation.

22. OPTN Plan for Evaluating The Committee will review annually:  How often this option is used  Mean MELD/PELD scores at transplant, number and % of candidates removed from the waiting list for reasons other than transplant for candidates with HCC exceptions versus those without, by Region  Outcomes for candidates whose exception is placed on hold

23. OPTN Additional Information Additional Data Collection: These proposals do not require additional data collection (forms) in Tiedi SM Expected Implementation Plan: UNOS Information Technology (IT) staff will need to reprogram UNet SM to implement these algorithms

24. OPTN Questions?