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. 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 policies toward continuous distribution framework

3. 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

4. What are the Possible Frameworks? • Fixed Concentric Circles • Variations in circle sizes • Hybrid Framework • Single fixed distance circle (500NM) • Variation in linear proximity point slope

5. Fixed Concentric Circles Framework

6. 150 NM/300 NM Fixed Concentric Circles

7. 250 NM/500 NM Fixed Concentric Circles

8. Hybrid Framework

9. Hybrid Model Single 500NM Circle

10. 500 NM Circle, No Proximity Points

11. 500 NM Circle, Shallow Proximity Points

12. 500 NM Circle, Steep Proximity Points Distance (NM) from Donor Hospital to Waiting List Candidate (Listing Center)

13. SRTR Modeling of Variations • Updated cohort of kidney, kidney-pancreas, pancreas candidates from Jan. 1 2017 – Dec. 31 2017 • Limitations: • 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

14. Results of 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

15. Results of SRTR Modeling • No impact on waitlist mortality across organs • Overall, modeling projected decline in transplant rates and counts for kidney and pancreas alone • Increased kidney-pancreas transplant rates compared to baseline

16. Projected Changes in Travel Distance Orange = Baseline (Current policy) Yellow = Hybrid framework variations Blue = Fixed Concentric Circle Variations

17. Specific Feedback Requested • Pancreas Committee presenter

18. Specific Feedback Requested • Which framework do you prefer? • Within the framework you selected, which circle size(s) do you prefer? • Which points variation do you prefer for the hybrid framework? • Should there be different distribution systems for kidney and pancreas organs?

19. 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 • Do you have suggestions of what to include in a subsequent SRTR modeling request by the KP Work Group?

20. Questions?

21. Extra Slides

22. 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.

23. 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.

24. 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

25. 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

26. Organ Center Travel Data (Kidney)

27. Kidney CIT vs. Travel Distance