Transplantation Surgical Director, Kidney Transplantation 2013 Douglas T. Miller Symposium on Organ
Donation and Transplantation Thursday, April 25, 2013The Transplant Waiting List
and
Organ Allocation Process
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Dixon B. Kaufman, MD, PhD Ray D. Owen Professor Chief, Division of
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- 1. Dixon B. Kaufman, MD, PhD Ray D. Owen Professor Chief, Division of
- 2. Presentation Objectives:Gain knowledge of state, regional, and
- 3. Waiting List Data and StatisticsUNOS: United Network
- 4. “The Gap” *Data based on snapshot of
- 5. Waiting ListsNationalRegionalLocalCenter
- 6. U.S. Waiting List Data and StatisticsSource: UNOS/OTPD.net, 4/5/13
- 7. Regional Waiting List Data and StatisticsSource: UNOS/OTPD.net, 4/5/13
- 8. Regional Waiting List Data and StatisticsSource: UNOS/OTPD.net, 4/5/13
- 9. WI Waiting List Data and StatisticsSource: UNOS/OTPD.net, 4/5/13
- 10. MI Waiting List Data and StatisticsSource: UNOS/OTPD.net, 4/5/13
- 11. IL Waiting List Data and StatisticsSource: UNOS/OTPD.net, 4/5/13
- 12. How long does the typical waitlisted patient wait for a transplant?Source: UNOS/OTPD.net, 4/5/13
- 13. UW OTD’s Laura Van Drese: Her Dad’s Story
- 14. UW Average Waiting TimesDeceased Donor Kidney Transplants
- 15. Necessary Steps to Getting on the Center
- 16. EvaluationSchedule Evaluation AppointmentSurgeonSocial WorkCertified DieticianFinancial CounselorPre-Transplant CoordinatorFurther TestingChest X-rayBlood WorkOther
- 17. Standard Evaluation TestingColonoscopy age
- 18. ApprovalMulti-Disciplinary Committee ReviewSignificant Coronary Artery DiseaseSignificant Vascular DiseaseMalignancy Non-ComplianceSubstance Abuse (Active)Poor Social/Financial SupportInsurance Approval
- 19. Two Types of TransplantationDeceased Donor: UNOS Waiting
- 20. Waiting: Complexities and ConstraintsMedical Preparationstay healthykeep
- 21. “I was at the top of the
- 22. Allocation: Matching Donor Organs With Transplant CandidatesSource: UNOS.org/TransplantLiving.org, 4/5/13
- 23. “Match Run”Factors affecting ranking may include: tissue
- 24. Kidney Donor Profile Index (KDPI)KDPI VariablesDonor ageHeightWeightEthnicityHistory
- 25. Current system does not include measure of
- 26. Four medical factors used to calculate Estimated
- 27. Candidates with CPRA >=98% face immense biological
- 28. New categories for highly sensitized candidates
- 29. Current policy prioritizes donors younger than 35
- 30. Continued priority pediatric candidates(now based on KDPI)
- 31. KDPI >85% kidneys would be allocated to
- 32. Proposed Regional Sharing
- 33. Current payback policy was evaluated and found
- 34. Priority within Classifications
- 35. Candidates are rank-ordered according to points within each classification.Proposed Changes to Point System
- 36. Proposed Point Changes: SensitizationCurrent policy: 4 points
- 37. Current policy begins waiting time points for adults at registration with:GFR
- 38. Simulated Policy Results
- 39. Scientific Registry of Transplant Recipients (SRTR) simulates
- 40. New system forecasted to result in: 8,380
- 41. KPSAM results by candidate age
- 42. KPSAM results by ethnicity
- 43. KPSAM results by CPRA
- 44. KPSAM results by CPRA (95-100%)
- 45. New system forecasted to result in: 8,380
- 46. Submit comments online: optn.transplant.hrsa.govAccess webinar
- 47. John J. Friedewald, MD Committee ChairRichard N.
- 48. UW OTD Services“Connect to Purpose Letter”
- 49. Слайд 49
- 50. Скачать презентанцию
Presentation Objectives:Gain knowledge of state, regional, and national statistics related to the transplant waiting list and transplantation.Develop an understanding of the complexities surrounding being on the transplant waiting list and the
Слайды и текст этой презентации
Слайд 1Dixon B. Kaufman, MD, PhD Ray D. Owen Professor Chief, Division of
Слайд 2Presentation Objectives:
Gain knowledge of state, regional, and national statistics related
to the transplant waiting list and transplantation.
Develop an understanding of
the complexities surrounding being on the transplant waiting list and the medical reasons why a patient is added to the transplant waiting list. Hear and understand the emotional and physical constraints of being on a transplant waiting list, waiting for the call, and being given a second chance at life.
Слайд 3Waiting List Data and Statistics
UNOS: United Network for Organ Sharing
OPTN:
Organ Procurement and Transplantation Network
Source: UNOS/OTPD.net, 4/5/13
Слайд 4“The Gap”
*Data based on snapshot of the UNOS, OPTN
waiting list and transplants on the last day of each
year.
Слайд 12How long does the typical waitlisted patient wait for a
transplant?
Source: UNOS/OTPD.net, 4/5/13
Слайд 14UW Average Waiting Times
Deceased Donor Kidney Transplants
Wait Time by
Blood Type
(Includes patients transplanted between 7/1/2010 - 6/30/2012)
ABO
Average days A 315
AB 286
B 684
O 811
Слайд 15Necessary Steps to Getting on the Center Waiting List
Your physician
must give you a referral
Contact a transplant hospital
Schedule an
appointment for an evaluation and find out if you are a good candidate for transplantIf the hospital's transplant team determines that you are a good transplant candidate, they will add you to the national waiting list
Source: UNOS.org/TransplantLiving.org, 4/5/13
Слайд 16Evaluation
Schedule Evaluation Appointment
Surgeon
Social Work
Certified Dietician
Financial Counselor
Pre-Transplant Coordinator
Further Testing
Chest X-ray
Blood Work
Other
Слайд 17 Standard Evaluation Testing
Colonoscopy age >50
Mammogram and Pap
Smear Annually
PSA age>50
Chest X-ray
Dental Clearance
Cardiac Testing
Vascular Testing
Слайд 18Approval
Multi-Disciplinary Committee Review
Significant Coronary Artery Disease
Significant Vascular Disease
Malignancy
Non-Compliance
Substance Abuse
(Active)
Poor Social/Financial Support
Insurance Approval
Слайд 19Two Types of Transplantation
Deceased Donor: UNOS Waiting list, UWHC Waiting
List
Live Donor: can be related or non-related
related by blood or
marriagenon-related directed donation
humanitarian non-directed donor donation
National Kidney Paired Exchange Program
Слайд 20Waiting: Complexities
and Constraints
Medical Preparation
stay healthy
keep your appts
Practical Preparation
stay organized
phone/email
tree
pack your bags
dependant care
transportation plan
Educational Preparation
learn, read, find a support
groupFinancial Preparation
create financial plan
talk to your family
POA
Spiritual Preparation
seek spiritual help or counseling.
Receiving “the call”
ALWAYS answer your phone
have directions to transplant center ready
Слайд 21“I was at the top of the liver waiting list,
too sick to be home with my family. While at
the hospital, my doctor said, ‘you have to eat’, but I couldn’t keep anything down, so they had to put a feeding tube in. Try taking twenty pills a day with a feeding tube down your throat. It was awful.” Lee Belmas, Liver Recipient“My original diagnosis was Type 1 Diabetes. I just assumed I would die at a young age. After my transplant, I felt like the windows of my house blew wide open. I saw brighter colors, a sense of hope, light, and excitement.” Nancy Garde, Kidney/Pancreas Recipient
Personal Constraints:
Physical and Emotional
Слайд 22Allocation: Matching Donor Organs With Transplant Candidates
Source: UNOS.org/TransplantLiving.org, 4/5/13
Слайд 23“Match Run”
Factors affecting ranking may include:
tissue match
blood type
length of time on the waiting list
immune status -
sensitization donor organ quality
distance between the potential recipient and the donor
degree of medical urgency (for heart, liver, lung and intestines)
Source: UNOS.org/TransplantLiving.org, 4/5/13
Слайд 24Kidney Donor Profile Index (KDPI)
KDPI Variables
Donor age
Height
Weight
Ethnicity
History of Hypertension
History of
Diabetes
Cause of Death
Serum Creatinine
HCV Status
DCD Status
KDPI values now displayed with
allorgan offers in DonorNet®
Слайд 25Current system does not include measure of potential longevity with
transplant
Longevity matching for some candidates could reduce the need for
repeat transplantsInclusion of Longevity Matching
Слайд 26Four medical factors used to calculate Estimated Post Transplant Survival
(EPTS)
Age
History of diabetes
Length of time on dialysis
History of a prior
transplant Inclusion of Longevity Matching
Слайд 27Candidates with CPRA >=98% face immense biological barriers
Current policy only
prioritizes sensitized candidates at the local level.
Proposed policy would give
following priorityTo participate in Regional/National sharing, review & approval of unacceptable antigens will be required
Proposed Classifications:
Very Highly Sensitized
Слайд 29Current policy prioritizes donors younger than 35 to candidates listed
prior to 18th birthday
Proposed policy would
Prioritize donors with KDPI
scores <35% Eliminate pediatric categories for non 0-ABDR KPDI >85%
Provides comparable level of access while streamlining allocation system
Modified Classification: Pediatric
Слайд 31KDPI >85% kidneys would be allocated to a combined local
and regional list
Would promote broader sharing of kidneys at higher
risk of discardDSAs with longer waiting times are more likely to utilize these kidneys than DSAs with shorter waiting times
Modified Classification:
Local + Regional for High KDPI Kidneys
Слайд 33Current payback policy was evaluated and found to be
Administratively challenging
Unfair
in that it affected all candidates in an OPO even
if only one center was responsible for accruing debtIneffective in improving outcomes of recipients
Kidney paybacks would no longer be permitted.
All payback credits and debts would be eliminated upon the implementation of the revised kidney allocation system.
Removed Classification:
Kidney Paybacks
Слайд 35Candidates are rank-ordered according to points within each classification.
Proposed Changes
to Point System
Слайд 36Proposed Point Changes: Sensitization
Current policy: 4 points for CPRA>=80%. No
points for moderately sensitized candidates. Proposed policy: sliding scale starting
at CPRA>=20%
Слайд 37Current policy begins waiting time points for adults at registration
with:
GFR
for dialysis time prior to registrationBetter recognizes time spent with ESRD as the basis for priority
Pre-emptive listing would still be advantageous for 0-ABDR mismatch offers
Proposed Point Changes: Waiting Time
Слайд 39Scientific Registry of Transplant Recipients (SRTR) simulates proposed policy changes
Kidney-Pancreas
Simulated Allocation Model (KPSAM)
50+ KPSAM runs conducted throughout policy development
4
KPSAM runs presented here for comparisonEvaluating Potential Policy Changes
Слайд 40New system forecasted to result in:
8,380 additional life years
gained annually
Improved access for moderately and very highly sensitized
candidatesImproved access for ethnic minority candidates
Comparable levels of kidney transplants at regional/national levels
Preview of Expected Outcomes
Слайд 45New system forecasted to result in:
8,380 additional life years
gained annually
Improved access for moderately and very highly sensitized
candidatesImproved access for ethnic minority candidates
Comparable levels of kidney transplants at regional/national levels
Summary
Слайд 46Submit comments
online:
optn.transplant.hrsa.gov
Access webinar schedules
Download educational materials
Participate in
Policy Development
Public
comment period ends December 14
Слайд 47John J. Friedewald, MD
Committee Chair
Richard N. Formica, Jr, MD
Committee Vice
Chair
Ciara J. Samana, MSPH
UNOS Committee Liaison
ciara.samana@unos.org
804-782-4073
Committee Leadership and Support
