Removal of DSA and Region from Kidney and Pancreas Distribution

1. Removal of DSA and Region from Kidney and Pancreas Distribution Kidney and Pancreas Transplantation Committees

2. Important Considerations • Proposed solutions represent a list of policy options the KP workgroup chose to model • KP Workgroup continues to consider framework variations not included in this concept paper • No decisions made about potential policy solutions • Concept paper is being pursued to solicit community feedback on Workgroup progress and findings as well as variation preferences • Kidney committee continues to deliberate further prioritization of pediatrics and prior living donor candidates in classification tables

3. What problem does the paper address? • Ensure compliance with the Final Rule by proposing potential solutions to remove DSA and region from allocation policies • Concept paper does not change policy • Purpose to inform and gather feedback on options for: • Removing DSA and region in kidney and pancreas distribution • Aligning allocation policies with the Final Rule • Moving kidney and pancreas policy towards singleallocation framework

4. What are the possible solutions? • Fixed concentric circle framework with a 150 nautical mile (NM) small circle and a 300 NM large circle • Fixed concentric circle framework with a 250 NM small circle and a 500 NM large circle • Fixed concentric circle framework with a single 500 NM circle • Hybrid framework with a single 500 NM circle that uses a small number of proximity points inside and outside of the circle • Hybrid framework with a single 500 NM circle that uses a large number of proximity points inside and outside of the circle

5. 150 NM/300 NM Fixed Concentric Circles

6. 250 NM Fixed Concentric Circles

7. 500 NM Fixed Concentric Circles

8. 500 NM Circle, No Proximity Points

9. 500 NM Circle, Shallow Proximity Points

10. 500 NM Circle, Steep Proximity Points Distance (NM) from Donor Hospital to Waiting List Candidate (Listing Center)

11. SRTR modeling of variations • Updated cohort of kidney, kidney-pancreas, pancreas candidates from Jan. 1 2017 – Dec. 31 2017 • No impact on waitlist mortality across organs • Lower kidney, pancreas transplant rates compared to baseline • Increased kidney-pancreas transplant rates compared to baseline

12. Limitations of KPSAM • Overall, modeling projected decline in transplant rates and counts for kidney and pancreas alone, however: • Modeling does not account for changes in behavior • Acceptance behavior likely to change in response to organ availability at a center • Previous experience with the SAMs suggests that they under-predict the number of transplants that would occur in reality if a given policy scenario were adopted • Transplant counts and rates unlikely to decline in reality

13. Impact on Subgroups in SRTR modeling • Pediatric kidney transplant rates increased compared to adults • High-cPRA kidney, kidney-pancreas and pancreas transplant rates increased • Relatively more kidney and pancreas transplants occurred in African-American recipients compared to white recipients • Relatively more kidney transplant counts for: • Recipients with > 10 years of dialysis time • Recipients with 0-DR mismatches

14. Projected changes in travel distance Orange = Baseline (Current policy) Yellow = Hybrid framework variations Blue = Fixed Concentric Circle Variations

15. Main metrics - Kidney Although the models show a reduction in transplants, this is likely because modeling is based on current acceptance behaviors that reflect allocation based on DSAs and OPTN Regions.

16. Main metrics – Kidney-pancreas Although the models show a reduction in transplants, this is likely because modeling is based on current acceptance behaviors that reflect allocation based on DSAs and OPTN Regions.

17. Specific Feedback Requested • What is your opinion of the 150/300 NM circles option? • What is your opinion of the 250/500 NM circles option? • What is your opinion of the 500 NM circle/no points option? • What is your opinion of the 500 NM circle/shallow points option? • What is your opinion of the 500 NM circle/steep points option? • Should there be different distribution systems for kidney and pancreas organs?

18. Specific Feedback Requested • How do you think replacing DSA and Region with either fixed concentric circles or the hybrid framework outlined in this presentation would affect organ acceptance behavior • Example: recovery practices of an OPO; evaluation of offers for a transplant program • Modeling is limited in predicting changes in transplant center and OPO behavior as a result of allocation policy changes

19. Questions?

20. Extra Slides

21. Collaboration between kidney and pancreas committees • Committees worked together to develop SRTR modeling for both allocation systems • Why for both? • Most pancreata transplanted as kidney-pancreas (KPs) • Could be logistically challenging to have different systems • Not clear why the distribution for pancreas and kidney would need to be different • However… • Through Committee and Workgroup deliberation, members recognized the distribution systems may need to have separate solutions

22. Collaboration between kidney and pancreas committees • Concerns raised about same distribution distances for kidney and pancreas: • Pancreata have different acceptable ischemic time from kidneys • Distribution of pancreas programs fewer in number and more spread out • Procurement methods may be different • Issues of organ scarcity and discard rate may apply differently for kidney and pancreas • Different challenges to applying hybrid solution to pancreas allocation than KAS, that has points • Conclusion- gather more feedback from community and gather more evidence to make informed decision based on Final Rule: • Demonstrate sound medical judgment with data driven evidence • Achieve best use of donated organs • Promote the efficient management of organ placement measured in travel time and costs