Enhancing Liver Distribution Liver and Intestinal Organ Transplantation

Enhancing Liver Distribution Liver and Intestinal Organ Transplantation Committee 1

What problem will the proposal solve? § Current liver distribution is limited by regional and DSA boundaries § Variation in median MELD at transplant by DSA ranges from 20 to 40 § § Equates to 3 -month mortality without liver transplant of 11% to nearly 100% Variation is greatest in nonexception candidates 2

What are the proposed solutions? § Proximity circles with 150 -mile radius around the donor hospital § Circles may extend out of the region § Expanded regional sharing, Share 29 to adult candidates within the region and/or circle § 5 MELD or PELD points to candidates within the circle § Separate allocation for DCD donors and donors at least 70 years old 3

What are the proposed solutions? Allocation of adult livers, non-DCD and age <70 Classification Candidates that are within the OPO’s: 1 Region or Circle 2 Region or Circle 3 Region or Circle 4 5 6 7 8 DSA Region or Circle Nation And are: Adult or pediatric status 1 A Pediatric status 1 B Any of the following: At least 18 years old at time of registration and calculated MELD of at least 29 12 to 17 years old at time of registration and allocation MELD of at least 29 Less than 12 years old at time of registration and allocation PELD of at least 29 MELD or PELD of at least 15 Adult or pediatric status 1 A Pediatric status 1 B MELD or PELD of at least 15 4

What are the proposed solutions? § § Candidates within the 150 -nautical mile circle receive 5 MELD or PELD proximity points Candidate age at time of registration on the waiting list: Proximity Points At least 18 years old 12 to 17 years old Less than 12 years old Five proximity points to their calculated MELD score Five proximity points to their allocation PELD score Candidates in the circle (both in and out of region) receive proximity MELD or PELD points 5

Proximity Circle Dashboard § Link 6

What are the proposed solutions? § New allocation for DCD or age > 70 donors Classification 1 2 3 4 7 8 9 10 11 12 § Candidates that are And are: within the OPO’s: Region or Circle DSA Region or Circle Nation DSA Region or Circle Nation Adult or Pediatric status 1 A Pediatric status 1 B MELD or PELD of at least 15 MELD or PELD less than 15 Prioritize local (DSA) allocation for this subset of donors 7

What are the proposed solutions? § Regional sharing will be “Region or Circle” for allocating all livers and liver-intestines (adult and pediatric) § § § Non-DCD pediatric livers: sharing within the region or circle for all candidates § § Candidates at programs within 150 miles of the donor hospital, and outside the region, would be included in “Region or Circle” allocation. “Regional allocation” will potentially include candidates outside the region (but within the proximity circle) Sharing threshold does not apply Status 1 A and 1 B candidates in the circle do not receive additional priority 8

Supporting Evidence § Previous modeling showed a similar concept that reduces variation in MELD at transplant and reduces travel less than the current system § Share 35 has increased access to urgent (MELD/PELD > 35) candidates § Proximity points will prevent livers traveling beyond 150 miles for small differences in MELD or PELD points § Region + Circle sharing does not rely on supply and demand metrics § Livers can travel to urgent candidates beyond DSA and regional boundaries § Without the potential logistical issues of sharing more broadly 9

Summary of LSAM Data: Current vs M 29 150 m § Variance in the MMa. T: All candidates 10 to 6 § Allocation MMa. T: § Median Transport Time (hours): § Median Distance Organs Travel (miles): § Percent Organs Flown: § Transplant Rate/Count : § Waiting List Mortality Rate/Count: § Post Tx Mortality Rate/Count: 29 to 29 1. 7 to 1. 74 88. 5 to 100. 7 50. 7 to 55. 2 0. 444/6651 to 0. 437/6651 0. 097/1455 to 0. 090/1366 0. 077/686 to 0. 077/682

How will members implement this proposal? § New relationships for liver transplant programs and OPOs outside their current region § Train OPO and Transplant Center staff on changes § No additional data collection required. 11

How will the OPTN implement this proposal? § Anticipated Board of Directors Review: Dec. 2017 § Significant programming effort § Educational opportunities to explain new distribution § Robust monitoring plan at 3 -month intervals § § Will share data with community Recent changes to HCC and NLRB expected to be implemented before this proposal 12

Specific feedback requested § Size of the proximity circle § Number of proximity points § Providing proximity points to the recovery DSA § Sharing threshold of lab MELD 29 for adult candidates § Separate allocation for DCD and age > 70 years old § Addressing the cap at MELD 40 13

Questions? Julie Heimbach, MD Committee Chair heimbach. julie@mayo. edu Matt Prentice, MPH Committee Liaison Matthew. prentice@unos. org 14